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High Output Heart Failure

High output heart failure is a poorly understood condition characterized by signs and symptoms of heart failure and a resting cardiac index above 4 l/min x m2. Classical heart failure treatment can be detrimental in this instance.


Presentation

Patients with high output heart failure present with dyspnea, tachypnea, non-productive cough, fatigability, pulmonary rales, pleural effusion and peripheral edema, as a result of pulmonary and venous congestion due to neurohormonal activation and increased salt and water retention. Also, they are often tachycardic, with a heart rate between 85 and 105 beats per minute. A third heart sound and bilateral basal crackles are often heard in these patients [1]. Jugular and femoral venous hum may be sometimes observed. Peripheral vasodilatation leads to warm extremities.

High output heart failure is caused by a number of conditions each with their own signs and symptoms, that can sometimes also be found in affected individuals, such as chronic anemia, systemic arterio-venous fistulae, Paget's disease, hyperthyroidism, chronic hypercapnia, obesity, beriberi heart disease and sepsis.

Anemia causes cutaneous pallor and fatigability which overlaps with that induced by the heart failure, peripheral vasodilatation caused by vascular nitric oxide synthase [2] and low systemic vascular resistance [3].

Arteriovenous fistulae are associated with a specific hum on auscultation and may be congenital or acquired. They lead to a decrease in the systemic vascular resistance and thus high output heart failure [4]. Fistulae may be found in the context of certain congenital diseases, such as Osler-Weber-Rendu disease, Parkes-Weber or Klippel–Trénaunay syndrome. They can cause decreased pulse pressure distal to their location [1].

Paget's disease is associated with pain and warmth of the affected area, but a large amount of bone must be involved before heart failure occurs. A similar mechanism for the malfunction of the heart has been described in multiple myeloma, and Albright's disease [5].

Hypercapnia caused by chronic obstructive pulmonary disease may also cause high output heart failure [6]. The pulmonary pathology is recognized by auscultation and symptoms like dyspnea and fatigability.

Hyperthyroidism causes tachycardia-mediated cardiomyopathy and thus high output heart failure [7] and is often accompanied by atrial fibrillation [8].

Sepsis causes systemic vasodilatation, arterial hypotension and heart failure [9] and is recognized most often using laboratory workup, but also by fever, tachycardia, and tachypnea.

Beriberi is associated with chronic alcohol consumption or impaired nutrient absorption, that lead to weight loss and steatorrhea. Heart beriberi causes peripheral edema and fatigability and decreased systemic vascular resistance, leading to high output heart failure.

Obesity leads to systolic and diastolic malfunction of the heart and increased total blood volume, thus causing high output heart failure [10].

Congestive Heart Failure
  • Her symptoms and cardiovascular changes were consistent with congestive heart failure and severe preeclampsia.[ncbi.nlm.nih.gov]
  • […] preserved ejection fraction [HFpEF] I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure[icd10coded.com]
  • Neonates typically present with severe congestive heart failure. Here we present a case in which a systolic heart murmur was the first manifestation of high output heart failure due to a VGAM.[ncbi.nlm.nih.gov]
  • Blood gas analysis and chest X-ray showed congestive heart failure. Enhanced computed tomography of the pelvis showed a 10 x 4 cm hypervascular tumor in the retroperitoneal space.[ncbi.nlm.nih.gov]
  • Congestive heart failure (CHF) is an important source of morbidity and mortality in end-stage renal disease patients. Although CHF is commonly associated with low cardiac output (CO), it may also occur in high CO states.[ncbi.nlm.nih.gov]
Anemia
  • High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism.[ncbi.nlm.nih.gov]
  • Anemia causes cutaneous pallor and fatigability which overlaps with that induced by the heart failure, peripheral vasodilatation caused by vascular nitric oxide synthase and low systemic vascular resistance.[symptoma.com]
  • These conditions include anemia , hyperthyroidism , and pregnancy.[hhcbehavioralhealth.org]
Collapse
  • Echocardiogram showed a dilated right ventricle with severe pulmonary hypertension and a non collapsing inferior vena cava (IVC).[ncbi.nlm.nih.gov]
  • It had an appropriate augmentation of flow and it collapsed on raising the arm above the level of the heart. However, on manually occluding the AVF, his heart rate decreased instantaneously from 105 bpm to 70 bpm.[omicsonline.org]
Dyspnea
  • After the procedure, dyspnea was improved and procedure related complication was not seen.[ncbi.nlm.nih.gov]
  • Endovascular sealing with a 16 60 mm bifurcated stent graft (S & G Biotech, Seoul, Korea) was performed which led to complete resolution of the patient's dyspnea.[ncbi.nlm.nih.gov]
  • A 64-year-old woman was admitted with systemic edema and exertional dyspnea. High-output heart failure was diagnosed by right heart catheterization and she was treated with diuretics.[ncbi.nlm.nih.gov]
  • A 40-year-old man who was referred to our hospital due to dyspnea was found to have high output cardiac failure on Swan-Ganz catheterization.[ncbi.nlm.nih.gov]
  • A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea.[ncbi.nlm.nih.gov]
Exertional Dyspnea
  • A 51-yr-old man presented exertional dyspnea as a consequence of iliocaval fistula combined with paradoxical pulmonary embolism and high-output heart failure.[ncbi.nlm.nih.gov]
  • A 64-year-old woman was admitted with systemic edema and exertional dyspnea. High-output heart failure was diagnosed by right heart catheterization and she was treated with diuretics.[ncbi.nlm.nih.gov]
  • A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea.[ncbi.nlm.nih.gov]
  • A 36-year-old male presented with progressive exertional dyspnea over months. Physical examination showed jugular venous distension, lung crecipitations, femoral bruit and pitting pedal edema.[ncbi.nlm.nih.gov]
  • Introduction In February, 2012, a 33-year-old man was admitted to our hospital because of exertional dyspnea, chest distress, and fatigue of 1 month duration. On admission, his blood pressure was 124/80 mm Hg and heart rate was 120 beats per minute.[circheartfailure.ahajournals.org]
Rales
  • Patients with high output heart failure present with dyspnea, tachypnea, non-productive cough, fatigability, pulmonary rales, pleural effusion and peripheral edema, as a result of pulmonary and venous congestion due to neurohormonal activation and increased[symptoma.com]
  • A chest examination detected no rales. Heart auscultation demonstrated accentuated first and second heart sounds, and grade 3/6 pansystolic ejection murmur in the mitral and tricuspid area.[circheartfailure.ahajournals.org]
  • Abstract Congestive heart failure describes a syndrome with complex and variable symptoms and signs, including dyspnea, increased fatigability, tachypnea, tachycardia, pulmonary rales, and peripheral edema.[ncbi.nlm.nih.gov]
  • […] of HF (see symptoms of left heart failure and symptoms of right heart failure ) Pulmonary edema with: Acute, severe dyspnea and orthopnea, worse when supine Cough (occasionally with frothing, blood-tinged sputum ) Cyanosis Auscultation of the lungs : rales[amboss.com]
Orthopnea
  • Orthopnea and paroxysmal nocturnal dyspnea are related to congestion of the pulmonary blood vessels and edema of the lung tissues.[medical-dictionary.thefreedictionary.com]
  • In fact, some physicians will ask patients to use terms such as ‘2 pillow’ or ‘3 pillow’ orthopnea to differentiate how severe their congestion is.[ausmed.com]
  • Pericardial tamponade Aortic dissection Cardiotoxic substances Renal failure Clinical features Rapid exacerbation of symptoms of HF (see symptoms of left heart failure and symptoms of right heart failure ) Pulmonary edema with: Acute, severe dyspnea and orthopnea[amboss.com]
  • Symptoms Breathlessness Duration and pattern Presence of orthopnea or paroxysmal nocturnal dyspnea Presence of frothy pink sputum Swelling of ankles Chest pain Ischemic or pleuritic in nature Exacerbating or relieving factors Palpitations Syncope Fatigue[clinicaladvisor.com]
Abdominal Bruit
  • A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula.[ncbi.nlm.nih.gov]
  • A continuous abdominal bruit was heard. Blood gas analysis and chest X-ray showed congestive heart failure. Enhanced computed tomography of the pelvis showed a 10 x 4 cm hypervascular tumor in the retroperitoneal space.[ncbi.nlm.nih.gov]
Steatorrhea
  • Beriberi is associated with chronic alcohol consumption or impaired nutrient absorption, that lead to weight loss and steatorrhea.[symptoma.com]
Heart Disease
  • .-) I50.1 Left ventricular failure, unspecified Inclusion term(s): Cardiac asthma Edema of lung with heart disease NOS Edema of lung with heart failure Left heart failure Pulmonary edema with heart disease NOS Pulmonary edema with heart failure I50.2[icd10coded.com]
  • ICD-10-CM Codes › I00-I99 Diseases of the circulatory system › I30-I52 Other forms of heart disease › I50- Heart failure › High output heart failure 2018 - New Code 2019 Billable/Specific Code I50.83 is a billable/specific ICD-10-CM code that can be used[icd10data.com]
  • They include: Obesity Liver disease Anemia Hyperthyroidism Pregnancy Lung disease Septic shock Paget's disease Arteriovenous fistula Beriberi heart disease Symptoms Common signs of high-output heart failure are similar to those of other types.[webmd.com]
  • For most adults, HF results from diminished myocardial contractility caused by ischemic heart disease. In contrast, decreased contractile states account for a smaller percentage of causes of pediatric HF.[pedsinreview.aappublications.org]
Tachycardia
  • Hyperthyroidism causes tachycardia-mediated cardiomyopathy and thus high output heart failure and is often accompanied by atrial fibrillation.[symptoma.com]
  • Patients may present with the usual signs of high-output heart failure including tachycardia, elevated pulse pressure, hyperkinetic precordium, and jugular venous distension.[ncbi.nlm.nih.gov]
  • Her EKG showed sinus tachycardia at 108 beats per minute. ECHO showed a normal ejection fraction with moderate mitral regurgitation.[shmabstracts.com]
  • Electrocardiography on presentation showed sinus tachycardia with asymmetrical T-wave inversion in lateral leads. A chest X-ray demonstrated cardiomegaly with no acute abnormality.[omicsonline.org]
  • These mechanisms are responsible for the symptoms of diaphoresis, cool skin, tachycardia, cardiac arrhythmias, and oliguria.[medical-dictionary.thefreedictionary.com]
Gallop Rhythm
  • On the third day of life, she developed cardiac failure with gallop rhythm, hepatomegaly and a murmur in the anterior fontanel; an echocardiogram confirmed clinic aggravation with biventricular dysfunction and right cavities and superior vena cava dilatation[ncbi.nlm.nih.gov]
  • ., infection) Examination Again, a full examination should be undertaken, with particular emphasis being paid to the following points: Hemodynamic parameters and vital signs Blood pressure – adequate perfusion pressure Heart rate and rhythm Gallop rhythm[clinicaladvisor.com]
Gallop Rhythm
  • On the third day of life, she developed cardiac failure with gallop rhythm, hepatomegaly and a murmur in the anterior fontanel; an echocardiogram confirmed clinic aggravation with biventricular dysfunction and right cavities and superior vena cava dilatation[ncbi.nlm.nih.gov]
  • ., infection) Examination Again, a full examination should be undertaken, with particular emphasis being paid to the following points: Hemodynamic parameters and vital signs Blood pressure – adequate perfusion pressure Heart rate and rhythm Gallop rhythm[clinicaladvisor.com]
Increased Jugular Venous Pressure
  • Physical findings are increased jugular venous pressure, tachycardia usually with a third heart sound, bilateral bibasilar crackles and a wide pulse pressure. The examination of the AVF may yield additional clues to diagnosis.[omicsonline.org]
Polyneuropathy
  • A diagnosis of Crow-Fukase syndrome was made based on the presence of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes.[ncbi.nlm.nih.gov]

Workup

Blood workup shows elevated levels of atrial and brain natriuretic peptide in high output heart failure patients [11] [12]. Venous oxygen saturation, if high (above 75%), is an indirect indicator of a high output state. The oxygen content of arterial and mixed venous blood samples is expected to be decreased.

As in all heart failure individuals, a chest radiography is useful, as it might show cardiomegaly, pleural effusion or pulmonary congestion. A diagnosis of pneumonia in a septic patient with high output heart failure should lead the physician to suspect it as the underlying cause of the failure.

The diagnosis is ultimately confirmed with echocardiography showing an increased cardiac index. This investigation may show eccentric remodeling, chamber dilatation, and increased ventricular filling pressures, with a high ejection fraction. Pulmonary hypertension is another common finding in these patients.

Cardiac catheterization confirms increased cardiac filling pressures, high pulmonary artery pressure, stroke volume, ventricular preload, ejection fraction and decreased afterload as a result of low systemic vascular resistance [13].

Hyperlactacidemia
  • The hyperlactacidemia completely resolved after amputation, and the high output cardiac failure has not recurred for two years. High output cardiac failure is rare in MD patients and is related to myocardial abnormalities and hyperlactacidemia.[ncbi.nlm.nih.gov]
Left Ventricular Hypertrophy
  • Left ventricular hypertrophy in these patients is characterized by a dilated ventricle and an increased left ventricular mass that is primarily due to the enlarged chamber diameter.[ncbi.nlm.nih.gov]
  • His transthoracic echocardiogram showed severe concentric left ventricular hypertrophy with an ejection fraction of 65%. There were no regional wall motion abnormalities detected but he had significant diastolic dysfunction.[omicsonline.org]
  • Bradycardia AV block Sinus tachycardia Atrial tachyarrhythmias Ventricular tachyarrhythmias Ischemia Left ventricular hypertrophy Low-voltage complexes Chest X-ray (CXR) A CXR should be performed in all these patients.[clinicaladvisor.com]

Treatment

  • Endovenous laser ablation treatment has become the less invasive therapeutic choice for the treatment of superficial venous insufficiency and varicose veins.[ncbi.nlm.nih.gov]
  • Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO).[ncbi.nlm.nih.gov]
  • In this case, we successfully used TACE in the treatment of hepatic EHE with high-output heart failure.[ncbi.nlm.nih.gov]
  • The authors also discuss the follow-up method, intervals, and threshold for further treatment for these lesions, and present a review of the literature.[ncbi.nlm.nih.gov]
  • Treatment with cardiopulmonary support and hemodiafiltration gradually improved his general condition, although it resulted in ischemic necrosis of the right leg.[ncbi.nlm.nih.gov]

Prognosis

  • Once the morphologic anomaly is detected, N-butyl-cyanoacrylate (NBCA) injection or other embolic agents are administered by means of radio-opaque agents. 10–12 These endovascular advancements have markedly improved the prognosis of VGAM in the past few[elsevier.es]
  • Symptoms of Congestive Heart Failure Symptoms of Congestive Heart Failure Rehabilitate Your Heart #Save a #Life CONGESTIVE HEART FAILURE (CHF) -- Description, causes, signs & symptoms, risk factors, diagnosis, treatment, prognosis, prevention.[pinterest.de]
  • References: [35] [36] [37] Prognosis[amboss.com]
  • J Am Coll Cardiol 2009;54:1747-1762 Cohn HN, Levine TB, Olivari MT, Garberg V, Lura D, Francis GS, Simon AB, Rector T: Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure.[karger.com]
  • Sadly, despite massive advances in diagnosis, therapy, and prognosis, the clinical pathway for most patients with heart failure continues to be one of ‘inexorable decline’.[ausmed.com]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • The etiology of his CHF together with the cardiomegaly and hyperdynamic left ventricular systolic function was unknown.[ncbi.nlm.nih.gov]
  • OBJECTIVES: This study sought to characterize the etiologies, pathophysiology, clinical and hemodynamic characteristics, and outcomes of high-output HF in the modern era.[ncbi.nlm.nih.gov]
  • Through noninvasive testing, hepatic arteriovenous malformation was diagnosed as the etiologic factor.[journals.lww.com]
  • The study authors found that most common etiologies of high-output HF (n 120) were obesity (31%), liver disease (23%), arteriovenous shunts (23%), lung disease (16%), and myeloproliferative disorders (8%).[acc.org]

Epidemiology

  • Back to Top Epidemiology It is difficult to estimate the incidence of PDB because most patients are asymptomatic.[clevelandclinicmeded.com]
  • References: [2] [3] Epidemiological data refers to the US, unless otherwise specified. Etiology The three major causes of heart failure are coronary artery disease, hypertension, and diabetes mellitus.[amboss.com]
  • Ch. 7-Epidemiology and Natural History of Vascular Malformations of the Central Nervous System. In: Jafar JJ, Awad IA, Rosenwasser R (eds).[hawaii.edu]
  • Epidemiology The prevalence of the ‘low cardiac output state’ is difficult to define.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • In the absence of cardiopulmonary pathophysiology, we presume that our patient's hemangioma was causing a right-to-left shunt as opposed to an expected left-to-right shunt.[ncbi.nlm.nih.gov]
  • The underlying pathophysiology was believed to be caused by the high-output state of pregnancy and by the increased peripheral vascular resistance of preeclampsia.[ncbi.nlm.nih.gov]
  • OBJECTIVES: This study sought to characterize the etiologies, pathophysiology, clinical and hemodynamic characteristics, and outcomes of high-output HF in the modern era.[ncbi.nlm.nih.gov]
  • Nevertheless, in all HF syndromes, whether adult or pediatric, a unifying pathophysiologic mechanism is involved: A cardiac injury (either congenital or acquired) activates both compensatory and deleterious pathways that cause a chronic and progressive[pedsinreview.aappublications.org]

Prevention

  • When addressing the problem of high-output heart failure, the nephrologist is faced with the dilemma of preventing progression of heart failure at the expense of loss of vascular access.[ncbi.nlm.nih.gov]
  • Treatment of the erythroderma flare can help prevent or treat the serious secondary complications.[shmabstracts.com]
  • […] the diastole phase of the cardiac cycle, which can occur when the mitral valve is narrowed, as in rheumatic mitral stenosis, or when there is an accumulation of fluid within the pericardial sac ( cardiac tamponade ) pressing against the ventricles, preventing[medical-dictionary.thefreedictionary.com]
  • However, VGAM can go undetected despite appropriate prenatal screening, and early detection and treatment after birth can prevent complications.[elsevier.es]
  • An accurate diagnosis will prevent morbidity and unnecessary hospital admissions.[omicsonline.org]

References

Article

  1. MacRae J, Levin A, Belenkie I. The cardiovascular effects of arteriovenous fistulas in chronic kidney disease: a cause for concern? Semin Dial 2006;19: 349-352.
  2. Ni Z, Morcos S, Vaziri N. Up-regulation of renal and vascular nitric oxide synthase in iron-deficiency anemia. Kidney Int. 1997;52:195-201.
  3. Anand I, Chandrashekhar Y, Ferrari R, et al. Pathogenesis of oedema in chronic severe anaemia: studies of body water and sodium, renal function, haemodynamic variables, and plasma hormones. Br Heart J. 1993; 70:357-362.
  4. Bourgeois N, Delcour C, Deviere J, et al. Osler-Weber-Rendu disease associated with hepatic involvement and high output heart failure. J Clin Gastroenterol. 1990; 12:236-238.
  5. Inanir S, Haznedar R, Atavci S, et al. Arteriovenous shunting in patients with multiple myeloma and high-output failure. J Nucl Med. 1998; 39:1-3.
  6. Anand I, Chandrashekhar Y, Ferrari R, et al. Pathogenesis of congestive state in chronic obstructive pulmonary disease. Studies of body water and sodium, renal function, hemodynamics, and plasma hormones during edema and after recovery. Circulation. 1992;86:12-21.
  7. Froeschl M, Haddad H, Commons AS, et al. Thyrotoxicosis-an uncommon cause of heart failure. Cardiovasc Pathol. 2005; 14:24-27.
  8. Watanabe H, Okamura K, Chinushi M, et al. Clinical characteristics, treatment, and outcome of tachycardia induced cardiomyopathy. Int Heart J. 2008;49:39-47.
  9. Rotheram E. High output congestive heart failure in septic shock. Chest. 1989;95:1367-1368.
  10. Galinier M, Pathak A, Roncalli J, et al. Obesity and cardiac failure. Arch Mal Coeur Vaiss. 2005;98:39-45.
  11. Yakes W, Rossi P, Odink H. How I do it. Arteriovenous malformation management. Cardiovasc Intervent Radiol. 1996:19: 65-71.
  12. Stern A, Klemmer P. High-output heart failure secondary to arteriovenous fistula. Hemodial Int. 2011; 15:104-107.
  13. Reddy Y, Melenovsky V, Redfield M, et al. High-Output Heart Failure. A 15-Year Experience. JACC. 2016;68(5):473-782.

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Last updated: 2019-06-28 10:12