Excerpt

A 45-year-old African-American female patient with uncontrolled hypertension and multiple sclerosis presented with worsening shortness of breath, dyspnea on exertion, orthopnea, and lower extremity edema over the last several months. On physical examination the patient had jugular venous distension, apical holosystolic murmur, rales in the lung bases, and grade 2+ edema in the lower extremities. Bruit was also discernable in the right upper quadrant. A transthoracic echocardiogram showed dilated right, left atrium and normal systolic function, mild diastolic dysfunction, mild mitral and tricuspid insufficiency, and an interatrial septal aneurysm with a negative jet in the bubble study due to high inferior vena cava (IVC) flow (Fig. 1). A transesophageal echocardiogram confirmed these findings and there was no evidence of an intracardiac shunt. A renal Doppler ultrasound showed normal size and velocities of the left renal artery but abnormal focal dilatation of the right renal artery with increased arterial flow velocities in both systole and diastole with spectral broadening (Fig. 2). A computed tomography (CT) angiogram showed a large right renal artery arteriovenous malformation (AVM) with early enhancement and dilation of the intrahepatic IVC (Fig. 3). Angiography of the right renal artery showed renal AVM draining into the IVC (Fig. 4). In summary, this is a case of a young female patient with high-output congestive heart failure and normal left ventricular systolic function with uncontrolled hypertension secondary to a renal AVM. The symptoms improved by medical treatment but the patient declined any invasive surgical interventions for treatment of the AVM. …