|Year : 2018 | Volume
| Issue : 6 | Page : 1280-1289
|Assessment of left ventricular mass changes after arteriovenous fistula surgical banding in end-stage renal disease
Camilo Cortesi1, Juan C Duque2, Sedki Mai1, Laisel Martinez3, Adriana Dejman2, Roberto Vazquez-Padron3, Loay Salman4, Marwan Tabbara3
1 Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
2 Katz Family Division of Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
3 DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
4 Division of Nephrology, Albany Medical College, Albany, NY, USA
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|Date of Submission||29-Oct-2017|
|Date of Decision||18-Dec-2017|
|Date of Acceptance||18-Dec-2017|
|Date of Web Publication||27-Dec-2018|
| Abstract|| |
Left ventricular hypertrophy (LVH) is a multifactorial complication frequently seen in patients with advanced chronic kidney disease. An arteriovenous fistula (AVF) is the preferred method for hemodialysis access. Once functional, AVFs demonstrate better patency rates and fewer complications when compared to other forms of vascular access. AVFs have been implicated in cardiac remodeling, but it is controversial whether those changes can be reversed by surgical ligation or blood flow reduction. In this study, we describe a cohort of asymptomatic patients with LVH who underwent AVF banding with a two-dimensional-echocardiogram done before and after the intervention to evaluate the association between AVF surgical banding and left ventricular mass (LVM) changes. Our results show that AVF surgical banding did not alter the left ventricular mass index (LVMI) with a mean prebanding LVMI of 70.3 ± 57.5 g/m2 and mean postbanding LVMI of 81.9 ± 55.9 g/m2, (P = 0.4). Our study shows that AVF flow reduction by surgical banding did not alter LVMI, and therefore LVH, in end-stage renal disease patients who have not yet shown clinical manifestations of cardiac disease.
|How to cite this article:|
Cortesi C, Duque JC, Mai S, Martinez L, Dejman A, Vazquez-Padron R, Salman L, Tabbara M. Assessment of left ventricular mass changes after arteriovenous fistula surgical banding in end-stage renal disease. Saudi J Kidney Dis Transpl 2018;29:1280-9
|How to cite this URL:|
Cortesi C, Duque JC, Mai S, Martinez L, Dejman A, Vazquez-Padron R, Salman L, Tabbara M. Assessment of left ventricular mass changes after arteriovenous fistula surgical banding in end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Mar 18];29:1280-9. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1280/248299
Camilo Cortesi∗, Juan C. Duque∗
∗These authors contributed equally to the manuscript.
| Introduction|| |
Left ventricular hypertrophy (LVH) is a common condition seen in end-stage renal disease (ESRD). It is reported that 75% of patients with chronic kidney disease (CKD) have LVH immediately prior to the initiation of dialysis;, whereas in earlier stages of CKD, the prevalence of LVH ranges from 32% to 75%., LVH has been associated with greater mortality and worse outcomes.,, Therefore, identifying the factors that can contribute to LVH regression may help decrease cardiovascular mortality in ESRD patients.
The etiology of LVH in ESRD patients is multifactorial and is thought to be the result of hemodynamic changes including chronic flow and pressure overload, as well as non-hemodynamic factors that are associated with uremia., Multiple patients experience cardiac remodeling with the progression of CKD even before arteriovenous fistula (AVF) creation.,
AVF is the preferred method of vascular access for hemodialysis (HD). However, it has been conventionally implicated as one of the main variables related to cardiovascular stress and subsequent remodeling in ESRD patients. The cardiac remodeling phenomenon has been well described and supported by various authors.,,, Creation of an AVF leads to increased venous return, preload and cardiac output, which are thought to trigger myocyte changes associated with wall hyper-trophy., Nevertheless, it is still questionable whether surgical banding of the AVF reverses cardiac remodeling as a result of reduction in cardiac output.
Regression of LVH has been reported in small prospective studies in the kidney transplant population after AVF closure.,, However, in this population, immunosuppressants have been described as a protective factor in the regression of cardiac remodeling.,, LVH regression in patients undergoing AVF banding is thought to be secondary to reduced blood flow and pressure overload. In addition to its potential benefits for LVH, AVF banding can be an esthetic solution for aneurysmatic AVFs or treatment of AVF complications such as arterial steal syndrome. AVF banding is also sometimes necessary after kidney transplantation in patients with underlying cardiac conditions presenting with worsening symptoms. In this posttransplant scenario, where the AVF is no longer being utilized, the worsening of symptoms (shortness of breath, orthopnea) is thought to be secondary to the hemodynamic changes caused by the presence of the AVF, since the partial or complete closure of the AVF can help alleviate symptoms depending on the individual patient.
In this study, we evaluated the association between AVF surgical banding and LVM changes in asymptomatic ESRD patients. To further analyze the potential relationship between the two, we assessed LVM changes in patients with AVF banding with partial and complete closure.
| Materials and Methods|| |
This is a retrospective, case–control study (a matched pair population) of adult patients with an echocardiographic evaluation performed before and after AVF surgical banding, done at the University of Miami Hospital – Jackson Memorial Health System between January 2009 and December 2014. A total of 22 asymptomatic patients were included. A total of 11 from the 22 patients underwent complete AVF closure, primarily for esthetic purposes, in which AVF was no longer cannulated after a successful kidney transplantation. The other 11 patients underwent partial banding of the AVF for safety and functional problems in aneurysmatic AVF outflows. None of the surgical banding procedures were done in patients with symptoms related to cardiac disease.
Demographic data including patients’ age and ethnicity, comorbidities, AVF type and location, and two-dimensional (2D)-echocardiogram measurements done before and after surgical banding were collected and analyzed.
Echocardiographic evaluation was obtained using standard M-mode and two-dimensional images. All echocardiogram measurements were done by the cardiologist in the echo-cardiography service, according to the recommendations of the American Society of Echocardiography.
LVH: cardiac evaluation was done using 2D-echocardiogram equations to calculate LVM, LVMI and body surface area [Table 1]. LVMI values >100 g/m2 in women and >131 g/m2 in men were considered positive for LVH.,,
Complete banding: defined as a complete ligation of the AVF, leading to complete interruption of blood flow to the fistula.
Partial banding: defined as a reduction of blood flow in the outflow tract of the AVF.
| Statistical Analysis|| |
Data is reported as mean ± standard deviation. Statistical analyses were performed using on Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) and GraphPad Prism (La J olla, CA, USA). Two-tailed paired t-tests were utilized to compare patients’ 2D-echocardiogram measurements before and after AVF banding. A P <0.05 was considered statistically significant.
| Results|| |
A total of 22 patients had 2D-echocardio-grams performed before and after banding. The interval time between the two sonograms was 1001.5 ± 655 days with an average of 584 days before surgical banding and 417 days post-procedure. The mean age at the time of the banding procedure was 62 ± 12.5 years. The ethnic composition of the patient population was 50% African-Americans, 41% Hispanics, and 9% Caucasian. The patient population consisted of 11 (50%) with an average weight and height of 80.8 ± 20.6 kg and 168.4 ± 10.2 cm, respectively. Comorbi-dities included hypertension, coronary artery disease, diabetes mellitus, and congestive heart failure, which were present in 21 (96%), 10 (46%), 14 (64%), and four (18%) of the patients, respectively. The types of AVF in the study consisted of 11 brachiobasilic (50%), eight brachiocephalic (36.3%), two radiocephalic (9%), and one brachioaxillary (4.5%). AVFs were predominantly left sided (96%). The majority of the patients had a previous internal jugular HD catheter (21 of 22, 96%) and six patients (27%) had a history of a previous AVF [Table 1].
Eleven patients (50%) underwent AVF banding with complete closure and the remaining 11 (50%) had partial closure. The mean age in the complete banding and partial banding sub-groups was 66.8 ±11.5 and 57.5 ± 13.3, respectively (P = 0.93; [Table 2]). Ethnic composition and gender distribution were also similar between the groups (P = 0.50 and 0.65, respectively). The mean weight in the complete closure and partial closure groups was 78 ± 17 kg and 80.1 ± 22 kg, respectively (P = 0.44), whereas the mean height was 167.2 ± 10.7 cm and 166.2 ± 13.5 cm (P = 0.42). The complete closure group consisted of seven brachiobasilic AVFs (63%), three brachio-cephalic (28%), and two radiocephalic (18%). Similarly, the partial closure group had six brachiobasilic AVFs (58.6%), four brachio-cephalic (36%), and one brachioaxillary (4.5%). The anatomical location of the AVFs was also similar in both groups, with 10 (90%) and 11 left arm AVFs (100%) in the complete and partial closure subsets, respectively.
|Table 2: Two-dimensional-echocardiogram measurements in the overall study population.|
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Echocardiographic evaluation of left ventricular hypertrophy
Echocardiographic measurements before and after AVF banding in the overall patient population showed no statistically significant differences across any of the M-Mode variables of LVH [Table 3] and [Table 4]. There was no significant change in the mean ejection fraction (EF) before and after AVF banding: 55.7% ± 11.0% and 55.5% ± 17.6%, respectively, (P = 0.35). End diastolic volume was 86.7 ± 37.7 mL before and 96.8 ± 26.7 mL after banding, (P = 0.84). LVM before banding was 186.8 ± 71.9 g and after banding was 193 ± 73.7 g (P = 0.54). As for LVMI, no statistical differences were observed with a prebanding mean of 100.5 ± 36.7 g/m2 and postbanding mean of 178.8 ± 86.5 g/m2, (P = 1.00). The relative wall thickness (RWT) before banding was 0.4% ± 0.3% and after banding was 0.3% ± 0.2% (P = 0.32) [Table 3].
|Table 3: Baseline characteristics in patient subgroups with partial and complete banding.|
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|Table 4: Two-dimensional-echocardiogram measurements in patients with partial and complete AVF banding.|
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In the complete closure group, echocardio-graphic measurements before and after AVF banding showed no statistically significant differences across any of the M-Mode variables of LVH [Table 5]. The mean EF before and after AVF banding was 57.5% ± 4.7% and 56.4% ± 19.3% (P = 0.42). LVM before banding was 172.9 ± 57.8 g and 202.3 ± 52.1 g after banding (P = 0.86). Similarly, LVMI before and after AVF banding was 93.6 ± 30.1 g/m2 and 178.6 ± 71.6 g/m2, respectively (P = 1.00). Finally, the RWT was 0.4% ± 0.4% before banding and 0.4% ± 0.1% after banding (P = 0.62).
|Table 5: Two-dimensional-echocardiogram measurements inpatients with complete AVF banding.|
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Similar to the complete banding group, echocardiographic measurements before and after AVF banding in the partial closure subset showed no statistically significant differences across any of the M-Mode variables of LVH [Table 6]. The mean EF mean before and after AVF banding was 53.6% ± 15% and 54.5% ± 16.5%, respectively (P = 0.40). LVM before banding was 200.8 ± 82.2 g and 183.9 ± 92.3 g after banding (P = 0.85), while LVMI was 107.5 ± 40.9 g/m2 and 173.1 ± 102.8 g/m2, respectively (P = 0.98). Finally, the RWT was 0.3% ± 0.1% before banding and 0.3% ± 0.2% after banding (P = 0.62).
|Table 6: Two-dimensional-echocardiogram measurements in patients with partial AVF banding.|
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| Discussion|| |
The physiological changes after AVF anastomosis provoke a hyperkinetic state that is thought to be an important component of the cardiac remodeling process., Volume overload and other conditions, i.e., anemia, commonly seen in the ESRD population contribute to this phenomenon.,
While the hemodynamic effects of AVFs have been well described, there is still controversy between the relationship that exists between the presence of an AVF and cardiac remodeling. Decrease in cardiac output and regression of cardiac hypertrophy have been described after AV access closure, in the setting of kidney transplantation and in situ ations where the AV access flow has been modified percutaneously or surgically.,
Regression of LVH following surgical banding of AVF in renal transplant patients has been reported in previous studies.,, However, it is unclear whether the decrease in ventricular mass is due to the restoration of normal fluid balance or due to the removal of the AVF. Thus far, there is only one prospective study describing the implications of AVF closure on cardiac function and structural findings in HD patients. This six-month observational study showed several echocardiographic modifications including significant improvement in LV EF, and significant decrease in LVM and LVMI with a more favorable shift of cardiac geometry towards normality.
Contrary to Movilli et al, we did not observe any statistically significant change in LVMI six months or more after AVF surgical banding in our study. It is possible that this discrepancy is due to the small number of patients evaluated in both studies (25 and 22 respectively) but also the underlying differences in the patient populations, since Movilli et al studied Italian patients, compared to mostly African-Americans and Hispanics in our cohort, who are well known to have a higher incidence of hypertension and left ventricular remodeling.,
Studies assessing the effect of AVFs on cardiovascular function have shown an increase in cardiac output and EF after AVF creation.,, Those changes are thought to occur secondary to an increase in venous return and right-side pressures, with reduction in total peripheral resistance and secondary cardiac adaptation. It is believed that these changes are followed by a neurohormonal and autonomic nervous system response, leading to the increase in cardiac mass. In the present study, we did not observe any changes in EF or LVM in the overall group of 22 patients after banding.
In addition, to the best of our knowledge, we are the first group to compare the effects of partial versus complete AVF banding on LVM. We did not find any statistically significant differences in LVM or cardiac function measurements before and after banding in patients with partial-closure and complete-closure banding.
| Conclusion|| |
Our study shows that AVF flow reduction by surgical banding did not alter LVMI, and therefore LVH, in ESRD patients that have not yet shown clinical cardiac symptoms. These findings need to be confirmed by larger prospective studies controlling for all variables that are associated with LVH.
| Limitations|| |
We are limited by the retrospective nature of the study and, with it, the variability in the timing of the echocardiograms. However, the matched pair design of the study helps control for the effect of comorbidities and other patient-related variables, which could have contributed otherwise to our findings.
Conflict of interest: None declared.
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Dr. Juan C Duque
Katz Family Division of Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL. 33136
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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