Impact of a large hemodialysis arteriovenous fistula: on myocardial protection during cardiopulmonary bypass.

Arteriovenous fistulae have a substantial impact on systemic hemodynamics, but their effect on cardiopulmonary bypass is not well understood. The left-to-right shunting of blood through an arteriovenous fistula can create flow problems during cardiopulmonary bypass. We present the case of a 59-year-old man with end-stage renal disease who underwent coronary artery bypass grafting. During surgery, a large brachiocephalic arteriovenous fistula provided excessive venous return to the heart, compromising the myocardial protection offered by cardiopulmonary bypass. We modified the venous cannulation from a 2-stage single cannula to a bicaval cannula and were then able to achieve cardioplegic arrest and myocardial protection with no further problems.