Myocardial revascularization in patients with chronic renal failure

J THoRAc

CARDIOV ASC SURG

79:625-627, 1980

Myocardial revascularization in patients with chronic renal failure Symptomatic coronary artery disease in patients with chronic renal failure can complicate their management in a dialysis program. Hypotension associated with hemodialysis and the anemia of chronic renal disease can produce anginal episodes refractory to medical management. Untreated coronary artery disease may be a contraindication to renal transplantation in an otherwise acceptable candidate. We have encountered three cases of coronary artery disease severe enough to necessitate coronary bypass in patients from our long-term hemodialysis program. All three patients had uncomplicated postoperative courses, none had perioperative infarction, and in all three patients postoperative angiography demonstrated patency of all grafts. One patient subsequently underwent successful renal transplantation; the other two patients have continued in hemodialysis since bypass. We believe our experience and the reported experience of others confirm the feasibility of coronary bypass grafting in patients with chronic renal failure.

Jack W. Love, M.D., Edward J. Jahnke, M.D., R. Bruce Mcfadden, M.D., James J. Murray, M.D., Ronald G. Latimer, M.D., William F. Gebhart, M.D., H. Vernon Freidell, M.D., Michael B. Fisher, M.D., Robert R. Urquhart, M.D., and Arthur Greditzer, M.D., Santa Barbara, Calif.

Weare aware of eight reported cases in the literature concerning patients with chronic renal failure who have had coronary bypass operation.':" Five of the eight had undergone previous renal transplantation, one patient had a kidney transplant after bypass grafting, and two of the eight patients were maintained on longterm hemodialysis without transplantation after bypass grafting. In an active long-term hemodialysis program at the Santa Barbara Cottage Hospital, we have encountered three patients with coronary artery disease severe enough to warrant coronary bypass operation. Our experience with these three patients is presented to help others who must evaluate and treat patients with the combination of chronic renal failure and ischemic heart disease. Case reports CAS E I. A 40-year-old white man was seen in February, 1974, with chronic renal failure and severe, progressive an-

From the Departments of Surgery, Medicine, and Psychiatry, Santa Barbara COllage Hospital, Santa Barbara, Calif. Presented at the Southern California ChapterMeeting of the American College of Surgeons, Long Beach, Calif., Jan. 21, 1979. Received for publication Aug. 9, 1979. Accepted for publication Aug. 28, 1979. Address for reprints: Jack W. Love,M.D., 2410FletcherAve., Suite 104, Santa Barbara, Calif. 93105.

gina pectoris. Renal failure was secondary to membranous glomerulonephritis, a diagnosis established by renal biopsy at another institution 3lh years earlier. He was maintained on long-term hemodialysis without incident until the summer of 1973, when angina pectoris developed. The angina was progressive despite optimal medical management. He was anemic from uremia. Coronary angiography, performed in December, 1973, revealed moderately impaired left ventricular function and triple coronary artery disease. The left anterior descending vessel was occluded and filled distally by collaterals. The circumflex coronary artery had a high-grade proximal lesion and the dominant right coronary artery had high-grade lesions proximally and distally. The patient was experiencing angina at rest and with each hemodialysis session. Angina during dialysis was so severe that his physicians felt that he could not continue on dialysis, and he was referred for coronary bypass grafting. The patient had been employed as a construction worker prior to his illness. A complicating feature was a history of chronic mental depression for which psychiatric consultation had been obtained. No psychiatric contraindication to operation was felt to exist. Preoperative preparation involved coordinating among physicians in nephrology, cardiology, cardiac surgery, anesthesiology, and psychiatry. To assure informed consent, we gave the patient and his family extensive details of risks and possible benefits of the operation. Particular concern was expressed for potential problems with bleeding, wound healing, and sepsis. The patient and his family agreed to proceed with the operation. On Feb. 27, 1974, the patient had a triple coronary bypass: saphenous vein from aorta to right coronary artery, right in-

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Thoracic and Cardiovascular Surgery

Table I. Reported cases of coronary bypass in patients with chronic renal failure Patient

Authors

Menzoian et al.! Sakurai et al." Lamberti et al." Beauchampet al. 4 Larsen et al." Siegel et al." Love et al.

Case no.

1 2 3 4 5 6 7 8 9 IO

II

Date

1974 1974 1975 1976 1976 1977 1979

Age

47 52 32 35 49 50 31 48 40 61 49

I

Race W

W W W

W W W

I

Cardiac procedure

Sex F

M M M M M M M M M M

LAD SVG ~ RCA, SVG ~ LAD SVG ~ LAD SVG ~ RCA + LVA resect. SVG~ LAD SVG ~ LAD, SVG ~ CCA SVG ~ RCA, SVG ~ LAD and diag. branch SVG ~ LAD, SVG ~ CCA, SVG ~ CCA SVG ~ RCA, RIMA ~ LAD, LIMA ~ CCA RIMA ~ RCA, LIMA ~ LAD SVG ~ RCA, LIMA ~ CCA

SVG~

Renal status

Transp. postop. On hemodialysis Transp. preop. Transp. preop. Transp. preop. Transp. preop. Transp. preop. On hemodialysis Transp. postop. On hemodialysis Transp. candidate

SVG, Saphenous vein graft. LAD, Left anterior descending coronary artery. RCA, Right coronary artery. LVA, Left ventricular aneurysm. CCA, Circumflex coronary artery. RIMA, Right internal mammary artery. LIMA, Left internal mammary artery. Transp.. Transplantation.

Legend,

ternal mammary artery to left anterior descending, and left internal mammary artery to circumflex coronary artery. No problems were encountered at operation and the patient had a totally uneventful postoperative course. There was no evidence of perioperative myocardial infarction. A total of 9 units of whole blood was transfused during and after operation. Standard prophylactic cephalosporin therapy was used for 5 days. All wounds healed by first intention, and sutures were removed on postoperative day 22. Angiography was performed in the early postoperative period, and all three bypass grafts were widely patent with good runoff. He was discharged from the hospital on the postoperative day 25. The patient was free of angina following the operation. On March 10, 1975, he had a cadaveric renal transplant at Cottage Hospital. He recovered from this procedure with a functional homograft and was discharged from the dialysis program. It was our hope that this young man would enjoy full rehabilitation to good health and gainful employment. Unfortunately, his chronic depression became more severe, Seven months after the renal transplant operation the patient committed suicide. CASE 2. A 61-year-old white man was admitted to Cottage Hospital in April of 1976 with preinfarctional angina pectoris and known renal failure secondary to chronic nephritis. He had been considered a candidate for enrollment in the longterm hemodialysis program when his rapidly progressive angina pectoris developed. Coronary angiography delineated two-vessel disease involving the dominant right and left anterior descending coronary arteries. On April 22, 1976, the patient had double coronary bypass, with the right internal mammary artery anastomosed to the right coronary artery and the left internal mammary artery anastomosed to the left anterior descending coronary artery. He recovered without complications. In the early postoperative period, an arteriovenous fistula was established in the right arm and the patient was started on long-term hemodialysis. Postoperative angiography revealed patency of both internal mammary grafts. The patient has been maintained on long-term hemodialysis for 32 months since operation. He is considered too old to be a candidate for renal transplantation. CAS E 3. A 49-year-old white man was admitted to Cottage

Hospital in April of 1977 . He was in the long-term hemodialysis program because of renal failure secondary to tuberculous nephritis. He had severe angina pectoris and congestive heart failure complicating the dialysis sessions. Cardiac catheterization confirmed cardiomyopathy with a calculated ejection fraction of 0.41 based on planigraphic analysis of the left ventriculogram in the right anterior oblique projection. High-grade obstructing lesions were seen in the proximal right coronary artery and in a large lateral circumflex vessel (the obtuse marginal branch). Coronary bypass was performed on April 11, 1977, and consisted of saphenous vein bypass of the right coronary artery lesion and left internal mammary artery bypass of the circumflex lesion. Recovery was uncomplicated and postoperative angiography demonstrated wide patency of both bypass grafts. The patient has continued in the long-term hemodialysis program and is on the waiting list for renal transplantation at this time. He has been free of angina with only mild symptoms of congestive heart failure since the coronary bypass operation.

Discussion These three cases are, we believe, the ninth, tenth, and eleventh to be reported with the combination of chronic renal failure and ischemic heart disease severe enough to warrant coronary bypass. They are the first such cases in which internal mammary artery bypass was used. When our first patient presented, there was only a single case report in the literature of this combination, the report by Menzoian and associates' in 1974. The reported cases, including ours, are summarized in Table I. With the first of our three patients, we had great concern for the potential problems of bleeding, impaired wound healing, and sepsis, secondary to uremia, in addition to the usual risks of cardiac operations in nonuremic patients. None of these problems occurred, and we were more relaxed with the next two patients, who also had uncomplicated postoperative

Volume 79 Number 4

Myocardial revascularization in renal failure

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April. 1980

courses. Two of our patients were on long-term dialysis at the time of coronary bypass grafting. Dialysis was performed just before the cardiac procedure and again on the first postoperative day, as described by others. 6 The physician is thereby enabled to make accurate volume adjustments in conjunction with hemodynamic pressure measurements. None of our patients had perioperative myocardial infarction, and all bypass grafts were shown to be patent by postoperative angiography. Our first patient had severe psychiatric disease in addition to, or perhaps because of, his renal and cardiac disease. Despite our awareness of this condition, and psychiatric care before and after the cardiac and transplant operations, he committed suicide. Renal transplantation and hemodialysis have been widely employed for two decades," and coronary bypass has been widely practiced for more than one decade since the first such procedure was performed in 1964. H In view of the widespread success of hemodialysis and renal transplantation, and the known increased incidence of coronary artery disease in uremic patients," it is surprising that there have been so few reports of coronary bypass in conjunction with renal dialysis or transplantation. One suspects that there have been many unreported cases. For example, two patients in our hemodialysis program not included in this report have had coronary bypass operations at other institutions. On the other hand, it may be that physicians are discouraged by the patient with two life-threatening problems. Perhaps many such patients are being denied the benefits of coronary bypass because the rehabilitation potential seems small. On the basis of our experience, we would urge careful and individual consideration of such patients. Hemodialysis and renal transplantations are established and effective therapy for chronic renal failure. Coronary bypass, despite its controversial aspects, is generally acknowledged to be effective for relieving angina pectoris. Our three patients needed hemodialysis but could not tolerate dialysis without obtaining surgical relief of their angina. It is common experience for patients to become hypotensive during dialysis. This may induce angina in a patient with coronary occlusive disease, and the anemia of renal failure can be an additive factor. We performed coronary bypass grafting in our three patients primarily to enable them to tolerate dialysis. All three patients survived the cardiac operation with a successful result and without complications. This experience suggests that coronary bypass should

be considered for its long-term rehabilitation potential in addition to its more immediate value for relieving angina pectoris in patients requiring renal dialysis. We agree with others who have shown that patients with chronic renal failure can be candidates for myocardial revascularization!"" and that such patients, given optimum care, can tolerate cardiac operation with low morbidity and mortality. 10

Addendum Following preparation and submission of this manuscript, we noted an article entitled "Cardiac Surgery and End-Stage Renal Disease," to be presented by B. K. Monson and colleagues at the January, 1980, meeting of the Society of Thoracic Surgeons. Those authors describe 19 patients with end-stage renal disease who underwent 20 separate cardiac operations from 1972 to 1979, with results that support the conclusions in our article. REFERENCES Menzoian JO, Davis RC, Idelson BA, Mannick JA, Berger RL: Coronary artery by-pass surgery and renal transplantation. A case report. Ann Surg 179:63-64, 1974 2 Sakurai H, Ackad A, Friedman HS: Aorto-coronary bypass graft surgery in a patient on home hemodialysis. Clin Nephrol 2:208-210, 1974 3 Lamberti 11, Cohn LH, Collins 11: Cardiac surgery in patients undergoing renal dialysis or transplantation. Ann Thorac Surg 19:135-141,1975 4 BeauchampGD, Sharma IN, Crouch T, Reed W, Killen DA, McCallister BD, Crockett JE, Bell HH: Coronary bypass surgery after renal transplantation. Am J Cardiol 37:1107-1110, 1976

5 Larsen PB, Gentsch TO, Anderson WW, Traad EA, Gosselin AJ: Coronary reconstruction in a patient with prior renal transplantation. A case report with long-term follow-up. Cardiovasc Dis Bull Texas Heart Inst 3: 169172, 1976

6 Siegel MS, Norfleet EA, Gitelman HJ: Coronary artery bypass surgery in a patient receiving hemodialysis. Arch Intern Med 137:83-84, 1977 7 Tilney NL, Strom TB, Vineyard GC, Merrill JP: Factors contributing to the declining mortality rate in renal transplantation. N Engl J Med 299:1321-1325, 1978 8 Garrett HE, Dennis EW, DeBakey ME: Aortocoronary bypass with saphenous vein graft. Seven year follow-up. JAMA 223:792-794, 1973 9 Merrill JP: Cardiovascular problems in patients on longterm hemodialysis. JAMA 228:1149,1974 10 Connors JP, Shaw RC: Considerationsin the management of open-heart surgery in uremic patients. J THoRAc CARmov ASC

SURG

75:400-404, 1978