Pulmonary artery wedge pressure (PAWP) and pulmonary artery pressure (PAP) before (left) and 10 min after manual compression of arteriovenous fistula (right). Mean PAWP decreased from 25 to 15 mm Hg, systolic PAP from 62 to 36 mm Hg, diastolic PAP from 20 to 14 mm Hg, and mean PAP from 37 to 23 mm Hg. It is noteworthy that the large v wave of PCWP became smaller after the compression, suggesting the elevated left atrial pressure due to volume overload dramatically decreased.

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... 67-year-old woman with a history of kidney transplantation for polycystic kidney disease for 9 years was admitted to the cardiology section for worsening heart failure. She had been diagnosed with chronic heart failure due to hypertensive heart disease and hospital- ized for worsening of symptoms three times within 1 year. Coronary artery disease had been ruled out by coronary angiography 1 year before admission. On admission, the patient's blood pressure was 134/46 mm Hg, pulse rate was 62 beats/min, and body temper- ature was 37.1 C. A clinical examination revealed jugular vein disten- sion, third heart sound, and late-inspiratory fine crackles at the lower lung field. She had a brachiobasilic arteriovenous fistula in her left lower arm, which had been created for hemodialysis 13 years prior. The patient denied any signs of limb ischemia due to a steal phenom- enon caused by the fistula. Chest radiography showed lung conges- tion with apparent cardiomegaly (Figure 1). Her estimated glomerular filtration rate was 42.6 mL/min, and her plasma brain- type natriuretic peptide level was 1,138.8 pg/mL. Transthoracic echocardiography (Figure 2, Video 1) showed a mildly enlarged but hyperkinetic left ventricle with hypertrophy, a severely enlarged left atrium, mild mitral regurgitation, restrictive left ventricular (LV) filling pattern, and severe pulmonary hypertension, suggesting elevated LV filling pressure due to a hypertrophied left ventricle. Intravenous nitro- glycerin and furosemide were started in addition to oral administra- tion of furosemide (100 mg/d), tolvaptan (15 mg/d), amlodipine (10 mg/d), olmesartan (40 mg/d), and doxazosin (2 mg/d), which had already been administered before the worsening. After admission, her symptoms were gradually relieved, and chest radiography confirmed the improvement of the lung congestion, resulting in termi- nation of intravenous furosemide and nitroglycerin on the ninth day. However, soon after their discontinuation, lung congestion recurred, and intravenous medication was resumed and continued thereafter. To determine the contribution of the shunt flow via the arteriovenous fistula to heart failure, echocardiography was performed during its manual compression, which revealed decreases in LV end-diastolic dimension from 62 to 57 mm, in cardiac output from 5.2 to 4.5 L/min, in pulmonary artery systolic pressure from 76 to 53 mm Hg, and in the ratio of transmitral early diastolic to late diastolic flow veloc- ity from 4.30 to 2.76 after 10 min of occlusion, without significant change in mitral regurgitation, suggesting reduced LV preload and decrease in the filling pressure ( Figure 3, Videos 2 and 3). To further confirm these echocardiographic findings, invasive hemodynamic monitoring was repeated during the same maneuvers. Similarly to the echocardiographic study, pulmonary artery wedge pressure with large v waves and pulmonary artery pressures were dramatically decreased ( Figure 4). Cardiac output estimated using Fick's principle decreased from 7.1 to 5.5 L/min, indicating 1.6 L/min of the shunt flow. On the basis of this dramatic improvement in hemodynamics by manual compression, surgical closure of arteriovenous fistula was performed. Immediately afterward, her symptoms diminished, and intravenous medication was discontinued without any sign of recur- rence. The patient was discharged on the 40th day. Echocardiography 6 months after discharge showed a reduction of LV size, which revealed prominent apical hypertrophy, and a slight decrease in tricuspid regurgitation within the grade of mild, along with decrease in LV filling pressure suggested by transmitral flow pattern and tricuspid regurgitation velocity ( Figure 5, Video ...