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A5714 - Right Heart Catheterisation: Is There a Role in Assessing Suitability for Complex Vascular Communication in Haemodialysis Patients?
Author Block: C. Orton, E. Shaw, B. Madden; Pulmonary Hypertension, St Georges Hospital, London, United Kingdom.
Background Complex vascular communication (CVC) is necessitated in patients with end stage renal failure (ESRF) requiring haemodialysis that have exhausted conventional means. Pulmonary hypertension (PH) is common in patients with ESRF and is a significant risk factor in the creation of complex arteriovenous fistulae (AVF) as increased premature venous return may be poorly tolerated by a strained right ventricle, leading to complications from haemodynamic instability to catastrophic circulatory collapse. Severe biventricular impairment additionally contraindicates arterio-arterial communication (AAC). Right heart catheterisation (RHC) is the gold standard in characterising PH and could therefore be used to determine the operative suitability of CVC and specifically complex AVF or AAC. Aims To elucidate whether RHC characterisation of PH parameters in patients with ESRF is useful in determining operative suitability for complex vascular communication. Methods Right heart catheterisation was performed in nine consecutive patients with ESRF requiring CVC with echocardiographic evidence of PH over a 12 month period, without complication. Data were retrospectively collated from electronic systems and analysed. Results Five of the nine patients were female. The mean age of the cohort was 65 years (range 45-79 years). All nine patients successfully underwent right heart catheterisation without complication and sufficient data were collected to determine CVC procedural suitability. Five of six patients with a peripheral vascular resistance (PVR) ≤3 wood units (wu) were deemed suitable for creation of complex AVF and underwent subsequent successful fashioning without complication. The sixth patient continues to receive peritoneal dialysis with ongoing consideration of AVF formation as necessary. Two patients with a PVR ≥4wu were deemed unsuitable for creation of complex AVF. In both, AAC was deemed suitable and performed without complication. One patient had severe biventricular impairment with RHC demonstrating an mPCWP of 31mmHg and PVR 5wu; surgical formation of CVC was therefore not performed. Conclusion Our findings support the use of RHC as a safe and reliable method in determining suitability for CVC formation in patients with ESRF. Invasive measurement of pulmonary pressures through RHC is the Gold Standard in assessing pulmonary haemodynamics and can therefore be used to determine operative suitability for such patients. We advocate that patients with a PVR ≤3WU can safely undergo complex AVF and that patients with a PVR ≥4WU, but without evidence of left heart failure as determined by an mPCWP ≤15mmHg, can safely undergo AAC.