Congestive Heart Failure Outcomes and Mortality after First Arteriovenous Access Creation

Introduction: Heart failure (HF) is often comorbid with ESRD. We characterized changes in heart failure and predictors of mortality after first-time hemodialysis access.

Methods: Single-institution retrospective review of patients receiving first-time arteriovenous fistula/graft (AVF/AVG) 2015-2022. Pre-operative HF with reduced (HFrEF) or preserved EF (HFpEF) defined as clinical diagnosis and LVEF<50% or diastolic dysfunction on pre-op ECHO.  Included all HFrEF; random samples of HFpEF and non-HF (n = 346). Paired T-tests performed for differences in EF and right ventricular systolic pressure (RVSP) before/after AVF/AVG. Univariate analyses identified variables correlating with mortality for Cox proportional hazards model for survival length after AVF/AVG.

Results: 70 patients with HFrEF, 84 with HFpEF, and 192 without HF. Compared with non-HF, HFrEF patients more often male, former smokers, and had COPD/prior stroke. HFpEF patients had higher BMI and had more diabetes, hypertension, COPD vs. non-HF.  HFpEF and non-HF patients experienced decreased EF following AVF/AVG (-3.5%, p=0.013 and -1.9%, p=0.047, respectively). HFrEF group experienced increased EF after AVF/AVG (+4.3%, p=0.002). No significant differences in pre/post-operative RVSP. Cox proportional hazards model predicting length of survival demonstrated radiocephalic fistula protected against mortality (HR 0.58, 95%CI 0.364-0.927); factors portending earlier mortality were HFpEF (HR 1.91, 95%CI 1.184-3.081), HFrEF (HR 1.80, 95%CI 1.078-2.991), history of stroke (HR 2.14, 95%CI 1.280-3.462), former smoking (HR 1.813, 95%CI 1.209-2.721). 

Conclusions: While both forms of HF predicted earlier mortality, EF in HFpEF and HFrEF responded differently to new AVF/AVG, while right heart function was unchanged. More investigation is warranted regarding mechanisms underlying differential response to AVF/AVG physiologic challenge.