Incidence and predictors of echocardiographic cardiac deterioration after arteriovenous access surgery

Introduction

Creation of an arteriovenous fistula or graft (AVF/AVG) for haemodialysis alters cardiovascular haemodynamics and may promote adverse cardiac remodelling. However, the extent and predictors of post-operative echocardiographic deterioration remain incompletely defined.

Purpose

To quantify echocardiographic changes following AVF/AVG creation and identify predictors of post-operative echocardiographic heart failure parameters.

Methods

We conducted a retrospective cohort study of 141 patients undergoing AVF/AVG creation with paired echocardiograms before and after surgery. Median follow-up was 226 days (interquartile range 96–510). Within-patient changes were analysed using paired statistical tests.

A composite post-operative echocardiographic heart failure endpoint was defined as new occurrence of any of the following: left ventricular ejection fraction <40%, pulmonary artery systolic pressure >35 mmHg, right ventricular systolic dysfunction, or new left ventricular dilation relative to baseline. Logistic regression was used to identify predictors of this composite outcome, with models adjusted a priori for age and sex.

Results

Mean left ventricular ejection fraction declined from 52.8±11.1% to 48.9±15.5% (mean change −3.4%, p=0.011). Left ventricular end-diastolic diameter did not change significantly overall. New left ventricular dilation occurred in 29 patients (20.6%), new left ventricular systolic dysfunction in 27 (19.1%), and worsening right ventricular systolic dysfunction in 6 (4.3%).

The composite echocardiographic heart failure outcome occurred in 68 patients (48%). Access flow >2000 mL/min was independently associated with the composite endpoint (adjusted odds ratio 2.47, 95% confidence interval 1.01–6.04; p=0.047). Event rates increased progressively across access flow strata (≤1500, 1501–2000, and >2000 mL/min).

Conclusions

Echocardiographic deterioration after AVF/AVG creation is frequent and heterogeneous. Very high access flow is independently associated with post-operative echocardiographic heart failure, supporting a threshold-dependent relationship between access flow and adverse cardiac remodelling.