Cardiac Surgery in Patients with End-Stage Renal Disease

CURRENT REVIEW

Cardiac Surgery in Patients with End-Stage Renal Disease Jose L. Zamora, M.D., James T. Burdine, M.D., Helena Karlberg, M.D., Salwa M. Shenaq, M.D., and George P. Noon, M.D. ABSTRACT In a retrospective study we analyzed the clinical features of 85 patients with end-stage renal disease who underwent cardiac operation. Seventy-eight patients were from reports in the literature, and 7 were from our experience. The cardiac procedures were primarily valve replacements and aortocoronary bypass (ACB) operations. The indication for valve replacement was most commonly infective endocarditis (73%), affecting most frequently the aortic valve (68%). The most common organism was Staphylococcus aureus, and there was a recent episode of angioaccess site infection in at least 17.5% of patients with documented endocarditis. The 30-day mortality was 57% for patients undergoing emergency valve replacement and only 3% for similar elective operations. Cumulative survival at 48 months was equal to that of the overall hemodialysis population not having cardiac operations. The mean age (50 years), male to female ratio (911,number of vessels bypassed per patient (2.41, and operative mortality for ACB were equal to those reported in comparable series of patients with normal renal function. Cumulative survival at 48 months for ACB patients was similar (60% versus 56%) to that of the overall hemodialysis population. Cardiac operations can be performed safely in patients with end-stage renal disease; the morbidity and mortality are similar to those encountered in patients with normal renal function. The long-term survival after cardiac procedures in patients with end-stage renal disease is similar to that reported for the overall hemodialysis population not having cardiac operations. In 1966, Lansing and collaborators [l]performed one of the first reported cardiac operations on a patient with end-stage renal disease, an aortic valve replacement with a Starr-Edwards prosthesis. In their report, which included 2 patients, they stated ”these patients presented extraordinary problems not only medically and surgically, but also philosophically” [ 11. The advances made since then in the management of renal diseases are many, and today there are a large number of patients on long-term hemodialysis who may theoretically be candidates for cardiac operations. Cardiovascular disease is the number one cause of death among these patients; its From the Departments of Surgery and Anesthesiology, Baylor College of Medicine, Houston TX. Address reprint requests to Dr.Zamora, Department of Surgery, State University of New York, Upstate Medical Center, 750 E Adams St, Syracuse, NY 13210.

113 Ann Thorac Surg 42:113-117, July 1986

complications need to be managed aggressively to obtain longer survival and improved quality of life for patients with end-stage renal disease.

Material and Methods We analyzed the clinical features of patients with endstage renal disease who underwent cardiac operations. We included 78 patients from all the reports known to us on this subject published until June, 1984, and 7 patients operated on by one of us (G. P. N.). Only patients who were affected with end-stage renal disease and were on maintenance hemodialysis or peritoneal dialysis or had undergone renal transplantation prior to the cardiac procedure were included in the study.

Results There were 85 patients in the study. Forty-five underwent aortocoronary bypass (ACB)(53%),37 had valvular operations (43.5%), and 3 had combined valvular and coronary operations (3.5%)(Table 1).Age and sex information was available on 75 patients. The mean age for patients undergoing ACB was 50 ? 10 years and for those having valvular procedures, 43 2 13 years. Men accounted for 90.5% of patients undergoing ACB (38/42) and 45% of valvular procedures (15/33) (Fig 1). There were 40 valvular procedures performed; 39 were valve replacements, and 1 was a valvoplasty. They included aortic valve procedures in 26 patients (65%), mitral valve procedures in 12 patients (30%), and both aortic and mitral valve procedures in 2 patients (5%)(Fig 2). Information was avaliable on the etiology of the valvular disease in 30 patients; it was septic in 22 patients (73%)and nonseptic in 8 (26%),and underlying valvular anomalies were present in 7 patients (23%)(Table 2). Of the patients with infective endocarditis, there was information on the causal agent in 15. The most common agent was Staphylococcus aureus (10 patients). Among the other agents were streptococcus, pseudomonas, and enterococcus. There were 7 (17.5%) emergency valve replacements. Specific information was provided on the valvular operation in 28 patients. Twenty-one had replacement with mechanical prostheses (9 Starr-Edwards, 9 Bjork-Shiley, 3 others), 6 had replacement with porcine valves, and 1 underwent valvoplasty. Aortocoronary bypass was performed in 48 patients between 1971and 1984. Data were available on the number of vessels bypassed in 45 patients: 1 vessel, 8 patients (17%);2 vessels, 14 patients (29%);3 vessels, 20 patients (42%);4 vessels, 2 patients (4%);and 5 vessels, 1

114 The Annals of Thoracic Surgery Vol 42 No 1 July 1986

Table 1. Summary of Published Data from Clinical Seriesa Reference Chawla et a1 [22] Francis et a1 [30] Love et a1 [31] Zamora et a1 [present study] Dupon et a1 [29] Haimov et a1 [6] 26 Othersb Total

Date of Report

No. of Patients

1977 1980 1980 1986 1980 1974 1968-1979

12 10 10 7 4 4 5

3 each

85 (100%)

Aortocoronary Bypass

Valve Replacement

4 8 6 6

8

0 0

21

4 4 17

45 (53%)

37 (43.5%)

Combination 0 2 1 0 0 0

0

3 1

0 3 (3.5%)

"For this summary, we reviewed the literature covering a 18-year period and included the present study. b[l-5, 8-21, 23-28, 321

VALVE REPLACEMENTS N = 33

REVASCULAREATIONS N = 42

Table 2. Etiology of Valvular Disease

Etiology

Male

Infective endocarditis Rheumatic heart disease Rheumatic heart disease + infective endocarditis Idiopathic Congenital

0 Female

Fig 1 . Sex distribution in 75 patients with end-stage renal disease undergoing cardiac procedures.

Total

"1

i

65%

Percent 50.

30 %

Fig 2. Distribution of cardiac valve procedures in 40 patients 0 9 valve replacements and 1 valvoplasty).

patient (2%).The average number of bypassed vessels per patient was 2.4. All operations were plotted according to the date of operation. Patients having combined coronary and valvular operations were listed separately for each one. Eighty-eight operations were performed between 1966 and 1984 (Fig 3). Ten patients operated on between 1966 and 1970 all had valvular procedures. Of 41 operations between 1971 and 1976, 19 (46%)were valvular and 22 (54%)were coronary; of 37 operations between 1977 and 1984, 10 (27%)were valvular and 27 (73%)coronary.

Aortic Valve

Mitral Valve

Aortic + Mitral Valve

Total

12

6

1

19

2

1

0

3

3

0

0

3

3 1

1 0

0 0

4 1

21

8

1

30

Preoperatively, 62 patients were maintained on hemodialysis and 7 on peritoneal dialysis; 16 had undergone renal transplantation. Seven patients who were on hemodialysis before operation received peritoneal dialysis postoperatively. There was no difference in the morbidity and mortality in these patients compared with those managed by postoperative hemodialysis. The time of the first postoperative dialysis was known in 33 patients: the first day in 18 patients, the second day in 12, and the third day in 3. Increased postoperative bleeding was the most frequently reported complication. It occurred in 9 patients (10.6%),2 of whom died perioperatively. Overall perioperative mortality for valve replacement was 12.5%(5/40);4 of 7 patients having emergency valve replacement and 1 of 33 having nonemergency valve replacement died (Table 3). All 5 patients who died after valve replacement had infective endocarditis, and 4 of them underwent emergency valve replacement. Perioperative mortality for coronary revascularization was 4.2% (2148) (see Table 3). Taking into consideration all cardiac procedures, there were 7 deaths within 30 days after operation, 5 after valve replacement and 2 after

115 Current Review: Zamora, Burdine, Karlberg, et al: Cardiac Surgery and End-Stage Renal Disease

*"I

nl

W Valve replacement 0 Coronary revascularlzation

20-

Number

Fig 3. Chronological distribution of cardiac operations performed from 1966 to 1984. This figure depicts an early preponderance of valvular procedures, a middle period of balanced distribution, and more recently a predominance of coronay revascularizations over valvular operations.

Table 3. Thirty-Day Perioperative Mortality

Coronary revascularization Valve replacement Overall Nonemergency Emergency

No. of Patients

No. of Deaths

48

2

%

4.2

Cause of Death

ACB

Ventricular fibrillation Sepsis, leg wound infection, postop myocardial infarction Sepsis

MVR (infective endocarditis) Emergency AVR (infective endocarditis) Emergency AVR/MVR (infective endocarditis) Emergency AVR (infective endocarditis) Emergency MVR

5 1 4

12.5

3.0 57.1

Total

0

1

17

1

1

1

26

1

Low cardiac output

0

1

Low cardiac output

1

1

Insulin overdose

2

1

Cerebrovascular accident

ACB = Aortocoronary bypass; MVR = aortic valve replacement.

40 33 7

rostop Day

Operation

ACB

10.

Procedure

Table 4. Causes of Perioperative Death

=

mitral valve replacement; AVR

] p < 0.001

ACB. The causes of death are listed in Table 4. The longterm survival estimated by life-table analysis revealed a cumulative survival at 48 months of 55% for patients undergoing valve replacement and 60%for those having coronary revascularization (Figs 4, 5).

Comment The cardiac operations reported among patients with end-stage renal disease have been primarily valve replacements and ACB [l-321. The distribution of these procedures has changed over the 18-year period evaluated in this study. The early experience (1966-1970) was all valve replacements. It was followed by a period of balanced distribution with myocardial revascularization (1971-1976). More recently (1977-1984), there has been a predominance of coronary over valvular procedures (see Fig 3). Likely explanations for this pattern are the following: the higher incidence of blood-borne infections associated with the Scribner shunt and other indwelling percutaneous techniques utilized in the late 1960s and early 1970s prior to the development and widespread acceptance of the Brescia-Cimino arteriovenous fistula; the development of coronary artery bypass techniques in the late 1960s and the staggering increase in the number of operations for coronary disease since; and the increase in the number and long-term survival of patients undergoing dialysis and transplantation therapy for end-stage renal disease.

Survival

0

5

10

15

20

25

30

35

40

45

Time (months) Fig 4. Survival curve for patients with end-stage renal disease undergoing cardiac valve operations.

The characteristicsof infective endocarditis in patients on hemodialysis have been described previously. They include involvement mostly of left-sided valves and predominance of staphylococcal infections [7,33, 341. It has been shown that heart failure usually secondary to valvular insufficiency is a major determinant of outcome, with a mortality of 45% for patients without failure and 100%in patients with failure [33]. Although in our study we observed the same characteristics, the mortality was much lower, undoubtedly the effect of surgical treatment. This pattern is similar to that in patients with normal renal function in whom early valve replacement has increased survival markedly j35-371. Our overall operative mortality for patients undergoing valve replacement was 12.5%; however, we identified a high-risk group, that is, those with infective endocarditis, who

116 The Annals of Thoracic Surgery Vol 42 No 1 July 1986

Survival

0

5

10

15

20

25

30

35

Time (months)

40

45

Fig 5 . Survival curve for patients with end-stage renal disease undergoing aortocoronary bypass operations.

required emergency valve replacement. These patients in contrast with 3% (1/ had a 57% 30-day mortality (4/7) 33) in those who underwent elective operation (p < 0.001). This finding strongly suggests early intervention in patients with these characteristics. In all 5 patients who died after valve replacement, there was infective endocarditis and 4 of them (80%) had undergone emergency replacement for cardiac decompensation. The cumulative survival at 48 months was 55%, which is virtually equal to that in the overall hemodialysis population not having cardiac operations [38]. The male to female ratio was approximately 1:l in patients undergoing valvular procedures and 9:l among ACB patients. The high male predominance, age, number of vessels bypassed (2.4), and mortality in the ACB patients are equal to what is reported in patients with normal renal function and coronary disease [39,40]. This supports the concept that atherosclerotic disease in patients with end-stage renal disease is not different from the overall population as previously thought (411. Instead of having accelerated atherosclerosis, these patients have an abundance of cardiovascular risk factors (38, 421 such as hypertension, hypertriglyceridemia, and diabetes. When these factors are separated and the patient population is adjusted to age, the incidence is the same as that in the population with normal renal function [43-471. In our study, there was a 60% cumulative survival after ACB at 48 months. This is lower than that reported in ACB patients with normal renal function; survival ranges from 60 to 85% according to the number of vessels bypassed [40]. However it is similar to that of patients having hemodialysis but not undergoing cardiovascular operations (56%)(381. Short-term results of cardiac operation among patients with end-stage renal disease are similar to those obtained in patients with normal renal function. The factors that complicate the perioperative period such as potassium management, bleeding, and timing of perioperative dialysis and fluid replacement have been discussed at length by others [22, 491 and if managed as recommended, yield satisfactory results. A 1984 report [48] demonstrated the good results of cardiac operation in patients with normally functioning renal allografts (including 5 diabetics). Morbidity and

mortality in these patients was similar to that in our report, but long-term survival was better (79% at 31 months). It would seem that the improved long-term result in this select group is secondary to their renal allograft just as successful renal transplantation has shown superior long-term results over maintenance dialysis. In summary, from our study we conclude that cardiac operations in patients with end-stage renal disease can be performed safely with satisfactory results. The perioperative mortality is virtually equal to that of patients with normal renal function, and the long-term survival determined by the underlying renal disease is similar to that of patients with end-stage renal disease not undergoing cardiac operations. In patients with infective endocarditis, when medical therapy is ineffective, valve replacement should be carried out early to avoid cardiac decompensation, which is accompanied by a high operative mortality.

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117 Current Review: Zamora, Burdine, Karlberg, et al: Cardiac Surgery and End-Stage Renal Disease

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