Access High output heart failure in patients with upper arm A‐V fistulae: Diagnosis and treatment
Bibliographic record
Abstract
Purpose: Arteriovenous fistula (AVF) is the preferred blood access for hemodialysis due to its longevity and resistance to infection. Little attention is given to the long‐term hemodynamic consequences of large left‐to‐right shunts, particularly in patients with brachial artery fistulae. Materials and Methods: We describe 9 patients (8 on dialysis, 1 post‐transplant), aged 25–73, who developed clinical heart failure, primarily due to large, upper arm AVFs. Results: 4/9 had access flows in excess of 2 liters/min, assessed by blood temperature monitoring. 6/9 had cardiac output measured by right heart catheterization, before and after shunt compression. One also underwent left heart catheterization with ventriculography. 3/9 had surgical reduction of the fistula, either by banding or by serial interposition of small caliber GoreTex graft. In 2/9 the shunt was ligated. One patient had heart failure in association with 2 large, upper arm AVFs, one of which was ligated. After years of improved cardiac symptoms, heart failure recurred in association with marked hypertrophy of his remaining AVF. Resting cardiac output in this patient was in excess of 11 liters/min. 2/9 experienced acute onset of heart failure within 1–3 days of angioplasty of a venous stenosis. One of these, with very poor baseline cardiac function, expired. Surgical revision or ligation was accompanied by clinical improvement in the 5 patients so treated. One of these expired of a stroke after two months of cardiac improvement. Conclusion: High output heart failure is under‐diagnosed in dialysis patients. Patients with large upper arm shunts are particularly at risk. Access flow should be assessed regularly and those with outputs >1.5 liters/min should be monitored closely for development of heart failure. Surgical correction is beneficial and indicated in symptomatic patients. Patient number Age/Sex Access type Years with access Flow (liters/min) Change CO (liters/min) Rx Outcome 1 37/M AVF 8 >2 1.7 Reduction Improved 2 26/M AVF 5 >2 2.4 Band Improved 3 73/M AVF 3 >2 1.5 Reduction Improved 4 45/M AVF 10 n/a 3.2 Reduction Improved 5 65/M AVF 4 >2 2.8 Band Improved 6 57/F AVG 4 1.2 1.8 7 39/F AVF 2 n/a n/a Ligate Improved 8 66/M AVG 0.3 0.7 n/a Ligate Improved 9 69/F AVF 0.25 n/a n/a Expired
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".