Although hemodialysis patients who initiate and maintain a permanent form of dialysis vascular access have improved all-cause and cardiovascular survival compared with those who use catheters, the presence of an arteriovenous fistula has been shown to have a short-term, adverse effect on cardiac function. Through its effect as a left-to-right extracardiac shunt, the arteriovenous fistula can increase cardiac workload substantially, and, in certain patients, result in a high-output state and resultant heart failure over time. Here we review the mechanisms by which dialysis arteriovenous access may promote the development of high-output cardiac failure in end-stage renal disease patients, describe risk factors for and the diagnosis of high-output heart failure, and suggest management strategies for patients who develop high-output heart failure.