An 83-year-old woman with end-stage renal disease (G5) received a left forearm arteriovenous (AV) shunt for vascular access 5 years before the current presentation. She had previously been hospitalized 12 times for heart failure but had not been admitted after creation of the fistula. Her renal function was maintained even with end-stage disease, and hemodialysis had been avoided. During a recent admission for heart failure treatment lasting approximately 3 weeks, an exacerbation of pulmonary hypertension (PH) was observed, and her prescriptions, including diuretics, were adjusted. Her medical condition improved, and she was discharged from the hospital under close observation. After discharge, dyspnea on effort gradually worsened. She presented again with dyspnea at rest and was readmitted for further examination and treatment for hypoxia. Transthoracic echocardiography revealed increased right ventricular systolic pressure caused by tricuspid regurgitation, suggesting exacerbation of her PH. After various examinations, we hypothesized that changes in hemodynamics resulting from the AV shunt might be affecting the onset and exacerbation of PH, so we closed the AV fistula. Right heart catheterization performed before and after shunt closure showed mean pulmonary artery pressures of 46 mmHg before closure and 37 mmHg after closure. We report a case of PH with challenging clinical management and hemodynamic changes associated with AV shunt creation.
