Perioperative management of biventricular failure after closure of a long-standing massive arteriovenous fistula

Purpose: To report the perioperative management of arteriovenous fistula (A VF) closure in a patient with high-output heart failure and pulmonary hyper tension. Clinical features: In a 71-yr-old man, closure of a long-standing massive A VF between the right femoral artery and vein was performed. After closure o f the AVF, his pulmonary artery pressure (PAP) increased from 52/21 mmHg to 68/26 mmHg, his cardiac index decreased from 5.27 L(.)min(-1.)m(-2) to 3.1 8 L(.)min(-1.)m(-2), and his pulmonary wedge pressure increased from 15 mmH g to 32 mmHg due to an acute increase in afterload. Go-administration of pr ostaglandin E-1 and a phosphodiesterase III inhibitor improved the cardiac index and the PAP Conclusions: Surgical closure of the fistula may not always lead to resolut ion of the high output cardiac failure. In this case, afterload management using arterial dilators (prostaglandin E-1, phosphodiesterase III inhibitor ), use of inotropic drugs (phosphodiesterase III inhibitor), and close atte ntion to volume status was crucial for a successful outcome after surgical AVF closure.