UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Causes and pathophysiology of high-output heart failure

Authors
Michael M Givertz, MD
Amir Haghighat, MD, FACC
Section Editor
Barry A Borlaug, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

While most patients with heart failure (HF), with either reduced or preserved ejection fraction, have low or normal cardiac output accompanied by elevated systemic vascular resistance, a minority of patients with HF present with a high-output state with low systemic vascular resistance.

This topic will discuss the causes and pathophysiology of high-output HF. Clinical manifestations, diagnosis, and management of high-output HF are discussed separately. The diagnosis and management of HF with reduced ejection fraction and HF with preserved ejection fraction are discussed separately. (See "Determining the etiology and severity of heart failure or cardiomyopathy" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)

EPIDEMIOLOGY

High-output HF is an uncommon type of HF. The prevalence of this disorder is uncertain, particularly since the potential contributory role of high-output syndromes to HF may not be appreciated in many cases. Although high-output states are uncommon as a sole cause of HF, they may more commonly contribute to HF in patients with underlying cardiovascular disease and reduced myocardial reserve. (See 'Role of concurrent cardiac conditions' below.)

In a Mayo Clinic series of 120 consecutive patients with high-output HF diagnosed between 2000 and 2014, the most common causes were morbid obesity (31 percent), liver disease (22.5 percent), arteriovenous shunts (22.5 percent), lung disease (16 percent), and myeloproliferative disorders (8 percent) [1]. This study excluded patients with physiologic (eg, pregnancy, fever, infection), iatrogenic (pulmonary vasodilator or inotrope administration), or congenital causes of high output, as well as patients with severe anemia (hemoglobin <8 mg/dL), hyperthyroidism, valvular heart disease, constrictive pericarditis, left ventricular systolic dysfunction (left ventricular ejection fraction <45 percent), cardiomyopathy, or heart transplantation.

PATHOPHYSIOLOGY

High-output HF is characterized by elevated cardiac output, low systemic vascular resistance (due to peripheral vasodilation or arteriovenous shunting), and low arterial-venous oxygen content difference; some types are associated with increased oxygen consumption (reflecting increased metabolic demand). In the setting of high-output HF, the elevation in cardiac output is greater than that required to meet metabolic demand [1].

                         
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Jan 11, 2018.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
References
Top
  1. Reddy YN, Melenovsky V, Redfield MM, et al. High-Output Heart Failure: A 15-Year Experience. J Am Coll Cardiol 2016; 68:473.
  2. Anand IS. High-output heart failure revisted. J Am Coll Cardiol 2016; 68:483.
  3. Anand IS, Florea VG. High Output Cardiac Failure. Curr Treat Options Cardiovasc Med 2001; 3:151.
  4. Holzem KM, Marmerstein JT, Madden EJ, Efimov IR. Diet-induced obesity promotes altered remodeling and exacerbated cardiac hypertrophy following pressure overload. Physiol Rep 2015; 3.
  5. Alcázar R, de la Torre M, Peces R. Symptomatic intrarenal arteriovenous fistula detected 25 years after percutaneous renal biopsy. Nephrol Dial Transplant 1996; 11:1346.
  6. Lekuona I, Laraudogoitia E, Salcedo A, Sádaba M. Congestive heart failure in a hypertensive patient (don't forget the stethoscope). Lancet 2001; 357:358.
  7. Sigler L, Gutiérrez-Carreño R, Martínez-López C, et al. Aortocava fistula: experience with five patients. Vasc Surg 2001; 35:207.
  8. Lebon A, Agueznai M, Labombarda F. High-output heart failure resulting from chronic aortocaval fistula. Circulation 2013; 127:527.
  9. Wasse H, Singapuri MS. High-output heart failure: how to define it, when to treat it, and how to treat it. Semin Nephrol 2012; 32:551.
  10. Malik J, Kudlicka J, Tesar V, Linhart A. Cardiac safety in vascular access surgery and maintenance. Contrib Nephrol 2015; 184:75.
  11. Santos E, Peral V, Aroca M, et al. Arteriovenous fistula as a complication of lumbar disc surgery: case report. Neuroradiology 1998; 40:459.
  12. Braverman AC, Steiner MA, Picus D, White H. High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting. Chest 1995; 107:1467.
  13. Colombato LA, Spahr L, Martinet JP, et al. Haemodynamic adaptation two months after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients. Gut 1996; 39:600.
  14. Ohlow MA, Secknus MA, von Korn H, et al. Incidence and outcome of femoral vascular complications among 18,165 patients undergoing cardiac catheterisation. Int J Cardiol 2009; 135:66.
  15. Kelm M, Perings SM, Jax T, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment. J Am Coll Cardiol 2002; 40:291.
  16. Geng W, Fu X, Gu X, et al. Safety and feasibility of transulnar versus transradial artery approach for coronary catheterization in non-selective patients. Chin Med J (Engl) 2014; 127:1222.
  17. Hahalis G, Tsigkas G, Kakkos S, et al. Vascular Complications Following Transradial and Transulnar Coronary Angiography in 1600 Consecutive Patients. Angiology 2016; 67:438.
  18. Sy AO, Plantholt S. Congestive heart failure secondary to an arteriovenous fistula from cardiac catheterization and angioplasty. Cathet Cardiovasc Diagn 1991; 23:136.
  19. Wermers RA, Tiegs RD, Atkinson EJ, et al. Morbidity and mortality associated with Paget's disease of bone: a population-based study. J Bone Miner Res 2008; 23:819.
  20. Kohrt H, Logan A, Temmins C, et al. Reversible high-output cardiac failure, an unusual marker of disease status in multiple myeloma. Leuk Lymphoma 2008; 49:581.
  21. McBride W, Jackman JD Jr, Grayburn PA. Prevalence and clinical characteristics of a high cardiac output state in patients with multiple myeloma. Am J Med 1990; 89:21.
  22. Inanir S, Haznedar R, Atavci S, Unlü M. Arteriovenous shunting in patients with multiple myeloma and high-output failure. J Nucl Med 1998; 39:1.
  23. Morales-Piga AA, Moya JL, Bachiller FJ, et al. Assessment of cardiac function by echocardiography in Paget's disease of bone. Clin Exp Rheumatol 2000; 18:31.
  24. Sanyal SK, Saldivar V, Coburn TP, et al. Hyperdynamic heart failure due to A-V fistula associated with Wilms' tumor. Pediatrics 1976; 57:564.
  25. Rodgers MV, Moss AJ, Hoffman M, Lipchik EO. Arteriovenous fistulae secondary to renal cell carcinoma. Clinical and cardiovascular manifestations: report of a case. Circulation 1975; 52:345.
  26. Hayek S, Kung R, Barb I, et al. Digging deep: high output heart failure in renal cell carcinoma. Am J Med 2014; 127:22.
  27. Lim FY, Coleman A, Polzin W, et al. Giant chorioangiomas: perinatal outcomes and techniques in fetoscopic devascularization. Fetal Diagn Ther 2015; 37:18.
  28. Szilagyi DE, Smith RF, Elliott JP, Hageman JH. Congenital arteriovenous anomalies of the limbs. Arch Surg 1976; 111:423.
  29. Dotan M, Lorber A. Congestive heart failure with diffuse neonatal hemangiomatosis--case report and literature review. Acta Paediatr 2013; 102:e232.
  30. Shah SS, Snelling BM, Sur S, et al. Scalp congenital hemangioma with associated high-output cardiac failure in a premature infant: Case report and review of literature. Interv Neuroradiol 2017; 23:102.
  31. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med 1998; 158:643.
  32. Pick A, Deschamps C, Stanson AW. Pulmonary arteriovenous fistula: presentation, diagnosis, and treatment. World J Surg 1999; 23:1118.
  33. Montejo Baranda M, Perez M, De Andres J, et al. High out-put congestive heart failure as first manifestation of Osler-Weber-Rendu disease. Angiology 1984; 35:568.
  34. Danchin N, Thisse JY, Neimann JL, Faivre G. Osler-Weber-Rendu disease with multiple intrahepatic arteriovenous fistulas. Am Heart J 1983; 105:856.
  35. Ginon I, Decullier E, Finet G, et al. Hereditary hemorrhagic telangiectasia, liver vascular malformations and cardiac consequences. Eur J Intern Med 2013; 24:e35.
  36. Shovlin CL, Awan I, Cahilog Z, et al. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179.
  37. Vaksmann G, Rey C, Marache P, et al. Severe congestive heart failure in newborns due to giant cutaneous hemangiomas. Am J Cardiol 1987; 60:392.
  38. Weitz NA, Lauren CT, Starc TJ, et al. Congenital cutaneous hemangioma causing cardiac failure: a case report and review of the literature. Pediatr Dermatol 2013; 30:e180.
  39. Hosono S, Ohno T, Kimoto H, et al. Successful transcutaneous arterial embolization of a giant hemangioma associated with high-output cardiac failure and Kasabach-Merritt syndrome in a neonate: a case report. J Perinat Med 1999; 27:399.
  40. Khanna D, Chakravarty P, Arora P, et al. Large multifocal cutaneous hemangioma along lines of Blaschko with cardiac failure treated with propranolol. Pediatr Dermatol 2015; 32:e18.
  41. Shin WJ, Song JG, Jun IG, et al. Effect of ventriculo-arterial coupling on transplant outcomes in cirrhotics: Analysis of pressure-volume curve relations. J Hepatol 2017; 66:328.
  42. Bernal V, Pascual I, Esquivias P, et al. Cardiac hemodynamic profiles and pro-B-type natriuretic Peptide in cirrhotic patients undergoing liver transplantation. Transplant Proc 2009; 41:985.
  43. Cichoz-Lach H, Celiński K, Słomka M, Kasztelan-Szczerbińska B. Pathophysiology of portal hypertension. J Physiol Pharmacol 2008; 59 Suppl 2:231.
  44. Milani A, Zaccaria R, Bombardieri G, et al. Cirrhotic cardiomyopathy. Dig Liver Dis 2007; 39:507.
  45. Schrier RW. Water and sodium retention in edematous disorders: role of vasopressin and aldosterone. Am J Med 2006; 119:S47.
  46. Pacca R, Maddukuri P, Pandian NG, Kuvin JT. Echocardiographic detection of intrapulmonary shunting in a patient with hepatopulmonary syndrome: case report and review of the literature. Echocardiography 2006; 23:56.
  47. Páll A, Czifra A, Vitális Z, et al. Pathophysiological and clinical approach to cirrhotic cardiomyopathy. J Gastrointestin Liver Dis 2014; 23:301.
  48. Yun D, Heywood JT. Metastatic carcinoid disease presenting solely as high-output heart failure. Ann Intern Med 1994; 120:45.
  49. Meijer WC, van Veldhuisen DJ, Kema IP, et al. Cardiovascular abnormalities in patients with a carcinoid syndrome. Neth J Med 2002; 60:10.
  50. Wilson BE, Newmark SR. Thyrotoxicosis-induced congestive heart failure in an urban hospital. Am J Med Sci 1994; 308:344.
  51. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med 2001; 344:501.
  52. Lewis BS, Ehrenfeld EN, Lewis N, Gotsman MS. Echocardiographic LV function in thyrotoxicosis. Am Heart J 1979; 97:460.
  53. Riaz K, Forker AD, Isley WL, et al. Hyperthyroidism: a "curable" cause of congestive heart failure--three case reports and a review of the literature. Congest Heart Fail 2003; 9:40.
  54. BREWSTER WR Jr, ISAACS JP, OSGOOD PF, KING TL. The hemodynamic and metabolic interrelationships in the activity of epinephrine, norepinephrine and the thyroid hormones. Circulation 1956; 13:1.
  55. Johnson PN, Freedberg AS, Marshall JM. Action of thyroid hormone on the transmembrane potentials from sinoatrial node cells and atrial muscle cells in isolated atria of rabbits. Cardiology 1973; 58:273.
  56. Goodkind MJ, Dambach GE, Thyrum PT, Luchi RJ. Effect of thyroxine on ventricular myocardial contractility and ATPase activity in guinea pigs. Am J Physiol 1974; 226:66.
  57. Siu CW, Yeung CY, Lau CP, et al. Incidence, clinical characteristics and outcome of congestive heart failure as the initial presentation in patients with primary hyperthyroidism. Heart 2007; 93:483.
  58. Biondi B. Mechanisms in endocrinology: Heart failure and thyroid dysfunction. Eur J Endocrinol 2012; 167:609.
  59. Di Bello V, Aghini-Lombardi F, Monzani F, et al. Early abnormalities of left ventricular myocardial characteristics associated with subclinical hyperthyroidism. J Endocrinol Invest 2007; 30:564.
  60. Forfar JC, Muir AL, Sawers SA, Toft AD. Abnormal left ventricular function in hyperthyroidism: evidence for a possible reversible cardiomyopathy. N Engl J Med 1982; 307:1165.
  61. Iskandrian AS, Rose L, Hakki AH, et al. Cardiac performance in thyrotoxicosis: analysis of 10 untreated patients. Am J Cardiol 1983; 51:349.
  62. Kahaly GJ, Kampmann C, Mohr-Kahaly S. Cardiovascular hemodynamics and exercise tolerance in thyroid disease. Thyroid 2002; 12:473.
  63. Teasdale SL, Inder WJ, Stowasser M, Stanton T. Hyperdynamic Right Heart Function in Graves' Hyperthyroidism Measured by Echocardiography Normalises on Restoration of Euthyroidism. Heart Lung Circ 2017; 26:580.
  64. Vieillard-Baron A, Cecconi M. Understanding cardiac failure in sepsis. Intensive Care Med 2014; 40:1560.
  65. Zaky A, Deem S, Bendjelid K, Treggiari MM. Characterization of cardiac dysfunction in sepsis: an ongoing challenge. Shock 2014; 41:12.
  66. Merx MW, Weber C. Sepsis and the heart. Circulation 2007; 116:793.
  67. Vielma AZ, León L, Fernández IC, et al. Nitric Oxide Synthase 1 Modulates Basal and β-Adrenergic-Stimulated Contractility by Rapid and Reversible Redox-Dependent S-Nitrosylation of the Heart. PLoS One 2016; 11:e0160813.
  68. Akbarian M, Yankopoulos NA, Abelmann WH. Hemodynamic studies in beriberi heart disease. Am J Med 1966; 41:197.
  69. Abelmann WH, Lorell BH. The challenge of cardiomyopathy. J Am Coll Cardiol 1989; 13:1219.
  70. Ikram H, Maslowski AH, Smith BL, Nicholls MG. The haemodynamic, histopathological and hormonal features of alcoholic cardiac beriberi. Q J Med 1981; 50:359.
  71. Essa E, Velez MR, Smith S, et al. Cardiovascular magnetic resonance in wet beriberi. J Cardiovasc Magn Reson 2011; 13:41.
  72. Ahmed M, Azizi-Namini P, Yan AT, Keith M. Thiamin deficiency and heart failure: the current knowledge and gaps in literature. Heart Fail Rev 2015; 20:1.
  73. Attas M, Hanley HG, Stultz D, et al. Fulminant beriberi heart disease with lactic acidosis: presentation of a case with evaluation of left ventricular function and review of pathophysiologic mechanisms. Circulation 1978; 58:566.
  74. Isgaard J, Arcopinto M, Karason K, Cittadini A. GH and the cardiovascular system: an update on a topic at heart. Endocrine 2015; 48:25.
  75. Giustina A, Mancini T, Boscani PF, et al. Assessment of the awareness and management of cardiovascular complications of acromegaly in Italy. The COM.E.T.A. (COMorbidities Evaluation and Treatment in Acromegaly) Study. J Endocrinol Invest 2008; 31:731.
  76. Damjanovic SS, Neskovic AN, Petakov MS, et al. High output heart failure in patients with newly diagnosed acromegaly. Am J Med 2002; 112:610.
  77. Petrossians P, Daly AF, Natchev E, et al. Acromegaly at diagnosis in 3173 patients from the Liège Acromegaly Survey (LAS) Database. Endocr Relat Cancer 2017; 24:505.
  78. Nakagawa H, Okayama S, Kamon D, et al. Refractory high output heart failure in a patient with primary mitochondrial respiratory chain disease. Intern Med 2014; 53:315.
  79. Hirose Y, Miida T, Yoshida K, et al. High-output heart failure in mitochondrial myopathy: a fulminant form with severe lactic acidosis and rhabdomyolysis. Intern Med 1993; 32:798.
  80. Engel PJ, Johnson H, Baughman RP, Richards AI. High-output heart failure associated with anagrelide therapy for essential thrombocytosis. Ann Intern Med 2005; 143:311.
  81. Singh P. A Case of Anagrelide-Induced Nonischemic Cardiomyopathy in a Patient With Essential Thrombocythemia. J Pharm Pract 2017; :897190017699774.
  82. Aessopos A, Kati M, Farmakis D. Heart disease in thalassemia intermedia: a review of the underlying pathophysiology. Haematologica 2007; 92:658.
  83. Pennell DJ, Udelson JE, Arai AE, et al. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281.
  84. Anand IS. Pathophysiology of anemia in heart failure. Heart Fail Clin 2010; 6:279.
  85. Brannon ES, Merrill AJ, Warren JV, Stead EA. THE CARDIAC OUTPUT IN PATIENTS WITH CHRONIC ANEMIA AS MEASURED BY THE TECHNIQUE OF RIGHT ATRIAL CATHETERIZATION. J Clin Invest 1945; 24:332.
  86. Metivier F, Marchais SJ, Guerin AP, et al. Pathophysiology of anaemia: focus on the heart and blood vessels. Nephrol Dial Transplant 2000; 15 Suppl 3:14.
  87. Mehta PA, Dubrey SW. High output heart failure. QJM 2009; 102:235.
  88. Teixeira RS, Terse-Ramos R, Ferreira TA, et al. Associations between endothelial dysfunction and clinical and laboratory parameters in children and adolescents with sickle cell anemia. PLoS One 2017; 12:e0184076.
  89. Balfour IC, Covitz W, Davis H, et al. Cardiac size and function in children with sickle cell anemia. Am Heart J 1984; 108:345.
  90. Nielsen B, Hales JR, Strange S, et al. Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment. J Physiol 1993; 460:467.
  91. Korn TS, Thurston JM, Sherry CS, Kawalsky DL. High-output heart failure due to a renal arteriovenous fistula in a pregnant woman with suspected preeclampsia. Mayo Clin Proc 1998; 73:888.
  92. Gong B, Baken LA, Julian TM, Kubo SH. High-output heart failure due to hepatic arteriovenous fistula during pregnancy: a case report. Obstet Gynecol 1988; 72:440.
  93. Elliott JA, Rankin RN, Inwood MJ, Milne JK. An arteriovenous malformation in pregnancy: a case report and review of the literature. Am J Obstet Gynecol 1985; 152:85.
  94. Swinburne AJ, Fedullo AJ, Gangemi R, Mijangos JA. Hereditary telangiectasia and multiple pulmonary arteriovenous fistulas. Clinical deterioration during pregnancy. Chest 1986; 89:459.