A 60-year-old man presents with a 4-month history of progressive dyspnea on exertion, orthopnea, and bilateral ankle edema. On examination, there is a continuous machinery murmur over the left scapular region. Blood pressure is 160/60 mmHg with wide pulse pressure. Echocardiogram shows left ventricular volume overload. What is the underlying vascular abnormality?

• A Aortic coarctation
• B Patent ductus arteriosus with Eisenmenger physiology
• C Arteriovenous fistula for hemodialysis access ✓
• D Ruptured sinus of Valsalva aneurysm into right ventricle

Explanation

This patient has high-output cardiac failure from an arteriovenous fistula (likely for hemodialysis). The continuous machinery murmur over the back/scapular region suggests a large AV fistula. Wide pulse pressure and LV volume overload are characteristic. While patent ductus arteriosus also causes a continuous murmur, it is typically infraclavicular and congenital. A ruptured sinus of Valsalva causes a sudden presentation. Coarctation causes hypertension with radiofemoral delay. The chronic progressive course and continuous murmur point to AV fistula.

Reference: Braunwald's Heart Disease, 12th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.