High output heart failure from an aortocaval fistula

We report a 50-year-old male who sustained a right abdominal stab wound 20 years ago requiring laparotomy and extensive repair, now presenting with worsening dyspnea on exertion and palpitations. Physical examination was remarkable for jugular venous distention, bilateral lower extremity edema, and a right abdominal pulsatile mass with audible bruit. Transthoracic echocardiogram revealed a left ventricular ejection fraction (LVEF) of 30%-35% and a severely dilated inferior vena cava (IVC) with turbulent flow. Computed tomography venography of the abdomen revealed a fistula between the IVC and right renal artery, with aneurysm of the IVC measuring 8 cm. Cardiac catheterization confirmed a high cardiac output of 12 l/min. The patient underwent endovascular repair of the fistula with the use of an Amplatzer septal occluder, and subsequent improvement in symptoms and LVEF. This case highlights a unique etiology of high output heart failure, treated successfully by novel endovascular means.