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Successful coronary artery bypass surgery in a patient with AIDS
1698
CASE REPORT MAHAN ET AL CARDIAC SURGERY AND AIDS
In conclusion, extracardiac, unruptured Valsalva aneurysms should be surgically repaired, even if asymptomatic, considering these severe complications. An operative procedure for this type of aneurysm should be carefully selected after confirming the extent of the abnormal lesion during the operation.
References 1. Mayer JH III, Holder TM, Canent RV. Isolated, unruptured sinus of Valsalva aneurysm. J Thorac Cardiovasc Surg 1975; 69:429–31. 2. Brandt J, Jogi P, Luhrs C. Sinus of Valsalva aneurysm obstructing coronary arterial flow: case report and collective review of the literature. Eur Heart J 1985;6:1069–73. 3. DeBakey ME, Lawrie GM. Aneurysm of sinus of Valsalva with coronary atherosclerosis. Successful surgical correction. Ann Surg 1979;189:303–5. 4. Sakai H, Lee T, Kajiyama H, et al. A case of unruptured aneurysm of the sinus of Valsalva associated with severe aortic regurgitation. J Cardiol 1994;24:147–52. 5. Frank AP, Bartley PG, Robert LK. Massive sinus of Valsalva aneurysm presenting with coronary insufficiency. Ann Thorac Surg 1997;64:1475– 6.
Successful Coronary Artery Bypass Surgery in a Patient With AIDS Vicki L. Mahan, MD, Jorge M Balaguer, MD, A. Thomas Pezzella, MD, Thomas J. Vander Salm, MD, and Brian J. Mady, MD Divisions of Cardiothoracic Surgery and Infectious Disease, UMass Memorial Health Care, Worcester, Massachusetts
We report the case of a 47-year-old man with AIDS who underwent a successful quadruple coronary artery bypass operation. The improving prognosis of patients with HIV/AIDS, in addition to the reported incidence of plasma lipid abnormalities in patients receiving protease inhibitors, are laying the groundwork for a larger population in which premature coronary artery disease develops. Operative risk, immunosuppressive effect of cardiopulmonary bypass, and practical considerations in the care of these patients are discussed. (Ann Thorac Surg 2000;70:1698 –9) © 2000 by The Society of Thoracic Surgeons
T
he risk of conventional cardiac surgery using cardiopulmonary bypass (CPB) in patients with acquired immune deficiency syndrome (AIDS) was thought to be very high. The immunosuppressive effect of CPB created the assumption that patients with AIDS were vulnerable to a wide variety of perioperative infections and that the CPB would have a negative impact on their survival by causing further damage in an already compromised immune system. Many cardiac surgeons considered the presence of AIDS a contraindication for conventional cardiac surgery. The growing population of patients with Accepted for publication Jan 22, 2000. Address reprint requests to Dr Balaguer, Department of Surgery, UMass Memorial Medical Center, 55 Lake Ave N, Worcester, MA 01655.
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2000;70:1698 –9
human immunodeficiency virus (HIV) and AIDS, their better short- and long-term prognosis, and the recent reports that protease inhibitors increase plasma lipids are setting the stage for a larger group of patients who may develop accelerated coronary artery disease (CAD) and might require surgical revascularization in the near future. We report a successful case of a conventional coronary artery bypass operation performed in a patient with AIDS. A 47-year-old man with a known history of CAD was admitted to UMass Memorial Health Care with unstable angina. His cardiac history was significant for congestive heart failure (CHF), hypertension, noninsulin dependent diabetes, and chronic renal insufficiency on a three-times a week dialysis regimen. He had no history of drug abuse. This patient was diagnosed with HIV infection in 1996 during an investigation for thrombocytopenia. The infection was presumably acquired through heterosexual transmission. The diagnosis of AIDS was made in 1997 based upon a CD4 count of 192/mm3. The patient’s HIV infection has been well controlled on antiretroviral therapy and no opportunistic infections or tumors have developed since the initial diagnosis. The immediate preoperative CD4 count was 251/mm3 and the viral load was less than 25 copy/mL. Cardiac catheterization demonstrated severe threevessel coronary artery disease with critical stenosis of the left anterior descending, diagonal, circumflex and right coronary arteries. The left ventricular ejection fraction was well preserved. A catheter-based procedure was ruled-out because the characteristics of the lesions were considered to put the patient at high risk for restenosis. A quadruple coronary artery bypass operation was performed with the assistance of CPB. The left internal mammary artery was used to graft the left anterior descending, and separate reverse saphenous vein segments were used to graft the diagonal, first obtuse marginal, and right coronary arteries. Aortic cross-clamp and cardiopulmonary bypass times were 110 and 156 minutes, respectively. Universal precaution protocol was followed at all times. Routine antibiotic prophylaxis was implemented before the operation and during the first and second postoperative days. There were no needlesticks or knifepoint injuries during the operation. The postoperative course was complicated by thrombosis of his dialysis access, which was corrected. The rest of his convalescence was totally uneventful and the patient was discharged home on the fifth postoperative day in stable condition. At a 6-week follow-up, the patient was free from angina and in NYHA functional class II. All of the wounds were healed, the sternum was stable, and the dialysis access was functioning well. He has not suffered any infections since hospital discharge. His CD4 count 6 weeks after surgery was 300/mm3 and his HIV viral load remained undetectable at less than 25 copy/mL. At a 10-month follow-up, he was doing well in regard to his cardiac condition and remained free of any infections. His CD4 count and HIV viral load at this time was 299/mm3 and less than 25 copy/mL respectively. 0003-4975/00/$20.00 PII S0003-4975(00)01092-1
Ann Thorac Surg 2000;70:1699 –701
Comment The presence of HIV or AIDS was nearly always considered a contraindication for cardiac surgery by the end of the 1980s [1]. The immunosupressive effect of CPB and the trauma of the surgical procedure were thought to carry a prohibitive risk, particularly for infections, in a patient population with an already compromised immune system. Despite this initial belief, and with the cumulative experience gained during the last decade of operating upon patients with AIDS, different risk groups within this patient population were identified [2– 4]. It become evident that prognosis was strongly influenced by the patient’s baseline condition. Patients with clinical evidence of AIDS and bacterial endocarditis and patients who were IV drugs users had a much worse outcome after cardiac surgery than patients who were operated on for CAD who were simply HIV positive [4] [8]. In the latter group, the results were encouraging. Although some patients have suffered progression to AIDS, it was difficult to determine if the surgical procedure was responsible for the progression. Patients with the diagnosis of AIDS based on CD4 count alone without any opportunistic infections or tumors, as was the case we report, appears to be in a favorable group at least in regard to short term outcome. Studies involving larger number of patients and longer follow-up will be necessary to confirm this initial impression. Although the risk for the surgical team of acquiring HIV infection during an operative procedure cannot be ignored, this event has never been documented. The cardiac surgery team is exposed to more blood contact and for longer periods of time than are practitioners in other surgical specialties. Multiple use of sharp instruments and small needles and frequent instrumentation of large vessels (with the risk of blood splash) are common during a cardiac operative procedure. Fortunately in this case, there was no accidental blood exposure in the operating room or in the intensive care unit. The value of strict adherence to universal precautions for all cases cannot be overemphasized. It is likely that cardiac surgery and other surgical procedures are occasionally performed without awareness that a patient is HIV positive. In fact, in high-risk areas such as the South Bronx, 5% of emergency room patients with no suspicion of HIV infection have positive test results [7]. Furthermore, other viral infections, including Hepatitis B and Hepatitis C, are more readily transmitted after blood exposure than is HIV. New antiretroviral therapies, particularly protease inhibitors, have significantly reduced the AIDS mortality rate [5]. This improved survival has resulted in a paradigm shift from caring for terminally ill patients to caring for patients with chronic illness. Although protease inhibitors have positively affected survival they may also cause plasma lipid abnormalities. Severe premature coronary artery disease believed secondary to protease inhibitors has been reported [6]. These converging factors of increasing age and hyperlipidemia are laying the groundwork for a larger population of patients with HIV or AIDS in whom CAD may develop. In patients like the one in this report, CHF and © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT KAPPERT ET AL CLOSED CHEST BILATERAL MAMMARY ARTERY GRAFTING
1699
unstable angina carry a much worse prognosis than the AIDS itself, and cardiac surgery should not be withheld. We believed that it would be reasonable to offer cardiac surgery with the use of cardiopulmonary bypass to patients who are HIV positive who have AIDS, particularly when the cardiac pathology is worse than the one influenced by their immunologic condition.
References 1. Condit D, Frater RWM. Human immunodeficiency virus and the cardiac surgeon: a survey of attitudes. Ann Thorac Surg 1989;47:182– 6. 2. Sousa Uva M, Jebara VA, Fabiani JN, et al. Cardiac surgery in patients with human immunodeficiency virus infection. indications and results. J Card Surg 1992;7:240 – 4. 3. Aris A, Pomar JL, Saura E. Cardiopulmonary bypass in HIV-positive patients. Ann Thorac Surg 1993;55:1104 – 8. 4. Flum DR, Tyras DH, Wallack MK. Coronary artery bypass grafting in patients infected with human immunodeficiency virus. J Card Surg 1997;12:98 –101. 5. Cameron DW, Heath-Chiozzi M, Danner S, et al. Randomized placebo-controlled trial of ritonavir in advanced HIV-1 Disease. Lancet; 1998;351:543–9. 6. Henry K, Melroe H, Huebsch J, et al. Severe premature coronary artery disease with protease inhibitors [Letter]. Lancet; 1998;351:1328. 7. Frater RW. As originally published in 1989: human immunodeficiency virus and the cardiac surgeon: a survey of attitudes. Updated in 1999. Ann Thorac Surg 1999; 67:1203– 4. 8. Paone G, Silverman N. Cardiac surgery in patients with HIV Disease. In: Kenneth L. Franco, MD, Ednward D. Verrier, MD, eds. Advanced therapy in cardiac surgery. Hamilton, Ontario: B.C. Decker, 1999:20 – 4.
Closed Chest Bilateral Mammary Artery Grafting in Double-Vessel Coronary Artery Disease Utz Kappert, MD, Romuald Cichon, MD, Jens Schneider, MD, Ina Schramm, MD, and Stephan Schu¨ler, MD, PhD Cardiovascular Institute, University of Dresden, Dresden, Germany
A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease. (Ann Thorac Surg 2000;70:1699 –701) © 2000 by The Society of Thoracic Surgeons Accepted for publication March 6, 2000. Address reprint requests to Dr Schu¨ler, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany; e-mail: [email protected].
0003-4975/00/$20.00 PII S0003-4975(00)02007-5
CASE REPORT MAHAN ET AL CARDIAC SURGERY AND AIDS
In conclusion, extracardiac, unruptured Valsalva aneurysms should be surgically repaired, even if asymptomatic, considering these severe complications. An operative procedure for this type of aneurysm should be carefully selected after confirming the extent of the abnormal lesion during the operation.
References 1. Mayer JH III, Holder TM, Canent RV. Isolated, unruptured sinus of Valsalva aneurysm. J Thorac Cardiovasc Surg 1975; 69:429–31. 2. Brandt J, Jogi P, Luhrs C. Sinus of Valsalva aneurysm obstructing coronary arterial flow: case report and collective review of the literature. Eur Heart J 1985;6:1069–73. 3. DeBakey ME, Lawrie GM. Aneurysm of sinus of Valsalva with coronary atherosclerosis. Successful surgical correction. Ann Surg 1979;189:303–5. 4. Sakai H, Lee T, Kajiyama H, et al. A case of unruptured aneurysm of the sinus of Valsalva associated with severe aortic regurgitation. J Cardiol 1994;24:147–52. 5. Frank AP, Bartley PG, Robert LK. Massive sinus of Valsalva aneurysm presenting with coronary insufficiency. Ann Thorac Surg 1997;64:1475– 6.
Successful Coronary Artery Bypass Surgery in a Patient With AIDS Vicki L. Mahan, MD, Jorge M Balaguer, MD, A. Thomas Pezzella, MD, Thomas J. Vander Salm, MD, and Brian J. Mady, MD Divisions of Cardiothoracic Surgery and Infectious Disease, UMass Memorial Health Care, Worcester, Massachusetts
We report the case of a 47-year-old man with AIDS who underwent a successful quadruple coronary artery bypass operation. The improving prognosis of patients with HIV/AIDS, in addition to the reported incidence of plasma lipid abnormalities in patients receiving protease inhibitors, are laying the groundwork for a larger population in which premature coronary artery disease develops. Operative risk, immunosuppressive effect of cardiopulmonary bypass, and practical considerations in the care of these patients are discussed. (Ann Thorac Surg 2000;70:1698 –9) © 2000 by The Society of Thoracic Surgeons
T
he risk of conventional cardiac surgery using cardiopulmonary bypass (CPB) in patients with acquired immune deficiency syndrome (AIDS) was thought to be very high. The immunosuppressive effect of CPB created the assumption that patients with AIDS were vulnerable to a wide variety of perioperative infections and that the CPB would have a negative impact on their survival by causing further damage in an already compromised immune system. Many cardiac surgeons considered the presence of AIDS a contraindication for conventional cardiac surgery. The growing population of patients with Accepted for publication Jan 22, 2000. Address reprint requests to Dr Balaguer, Department of Surgery, UMass Memorial Medical Center, 55 Lake Ave N, Worcester, MA 01655.
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2000;70:1698 –9
human immunodeficiency virus (HIV) and AIDS, their better short- and long-term prognosis, and the recent reports that protease inhibitors increase plasma lipids are setting the stage for a larger group of patients who may develop accelerated coronary artery disease (CAD) and might require surgical revascularization in the near future. We report a successful case of a conventional coronary artery bypass operation performed in a patient with AIDS. A 47-year-old man with a known history of CAD was admitted to UMass Memorial Health Care with unstable angina. His cardiac history was significant for congestive heart failure (CHF), hypertension, noninsulin dependent diabetes, and chronic renal insufficiency on a three-times a week dialysis regimen. He had no history of drug abuse. This patient was diagnosed with HIV infection in 1996 during an investigation for thrombocytopenia. The infection was presumably acquired through heterosexual transmission. The diagnosis of AIDS was made in 1997 based upon a CD4 count of 192/mm3. The patient’s HIV infection has been well controlled on antiretroviral therapy and no opportunistic infections or tumors have developed since the initial diagnosis. The immediate preoperative CD4 count was 251/mm3 and the viral load was less than 25 copy/mL. Cardiac catheterization demonstrated severe threevessel coronary artery disease with critical stenosis of the left anterior descending, diagonal, circumflex and right coronary arteries. The left ventricular ejection fraction was well preserved. A catheter-based procedure was ruled-out because the characteristics of the lesions were considered to put the patient at high risk for restenosis. A quadruple coronary artery bypass operation was performed with the assistance of CPB. The left internal mammary artery was used to graft the left anterior descending, and separate reverse saphenous vein segments were used to graft the diagonal, first obtuse marginal, and right coronary arteries. Aortic cross-clamp and cardiopulmonary bypass times were 110 and 156 minutes, respectively. Universal precaution protocol was followed at all times. Routine antibiotic prophylaxis was implemented before the operation and during the first and second postoperative days. There were no needlesticks or knifepoint injuries during the operation. The postoperative course was complicated by thrombosis of his dialysis access, which was corrected. The rest of his convalescence was totally uneventful and the patient was discharged home on the fifth postoperative day in stable condition. At a 6-week follow-up, the patient was free from angina and in NYHA functional class II. All of the wounds were healed, the sternum was stable, and the dialysis access was functioning well. He has not suffered any infections since hospital discharge. His CD4 count 6 weeks after surgery was 300/mm3 and his HIV viral load remained undetectable at less than 25 copy/mL. At a 10-month follow-up, he was doing well in regard to his cardiac condition and remained free of any infections. His CD4 count and HIV viral load at this time was 299/mm3 and less than 25 copy/mL respectively. 0003-4975/00/$20.00 PII S0003-4975(00)01092-1
Ann Thorac Surg 2000;70:1699 –701
Comment The presence of HIV or AIDS was nearly always considered a contraindication for cardiac surgery by the end of the 1980s [1]. The immunosupressive effect of CPB and the trauma of the surgical procedure were thought to carry a prohibitive risk, particularly for infections, in a patient population with an already compromised immune system. Despite this initial belief, and with the cumulative experience gained during the last decade of operating upon patients with AIDS, different risk groups within this patient population were identified [2– 4]. It become evident that prognosis was strongly influenced by the patient’s baseline condition. Patients with clinical evidence of AIDS and bacterial endocarditis and patients who were IV drugs users had a much worse outcome after cardiac surgery than patients who were operated on for CAD who were simply HIV positive [4] [8]. In the latter group, the results were encouraging. Although some patients have suffered progression to AIDS, it was difficult to determine if the surgical procedure was responsible for the progression. Patients with the diagnosis of AIDS based on CD4 count alone without any opportunistic infections or tumors, as was the case we report, appears to be in a favorable group at least in regard to short term outcome. Studies involving larger number of patients and longer follow-up will be necessary to confirm this initial impression. Although the risk for the surgical team of acquiring HIV infection during an operative procedure cannot be ignored, this event has never been documented. The cardiac surgery team is exposed to more blood contact and for longer periods of time than are practitioners in other surgical specialties. Multiple use of sharp instruments and small needles and frequent instrumentation of large vessels (with the risk of blood splash) are common during a cardiac operative procedure. Fortunately in this case, there was no accidental blood exposure in the operating room or in the intensive care unit. The value of strict adherence to universal precautions for all cases cannot be overemphasized. It is likely that cardiac surgery and other surgical procedures are occasionally performed without awareness that a patient is HIV positive. In fact, in high-risk areas such as the South Bronx, 5% of emergency room patients with no suspicion of HIV infection have positive test results [7]. Furthermore, other viral infections, including Hepatitis B and Hepatitis C, are more readily transmitted after blood exposure than is HIV. New antiretroviral therapies, particularly protease inhibitors, have significantly reduced the AIDS mortality rate [5]. This improved survival has resulted in a paradigm shift from caring for terminally ill patients to caring for patients with chronic illness. Although protease inhibitors have positively affected survival they may also cause plasma lipid abnormalities. Severe premature coronary artery disease believed secondary to protease inhibitors has been reported [6]. These converging factors of increasing age and hyperlipidemia are laying the groundwork for a larger population of patients with HIV or AIDS in whom CAD may develop. In patients like the one in this report, CHF and © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT KAPPERT ET AL CLOSED CHEST BILATERAL MAMMARY ARTERY GRAFTING
1699
unstable angina carry a much worse prognosis than the AIDS itself, and cardiac surgery should not be withheld. We believed that it would be reasonable to offer cardiac surgery with the use of cardiopulmonary bypass to patients who are HIV positive who have AIDS, particularly when the cardiac pathology is worse than the one influenced by their immunologic condition.
References 1. Condit D, Frater RWM. Human immunodeficiency virus and the cardiac surgeon: a survey of attitudes. Ann Thorac Surg 1989;47:182– 6. 2. Sousa Uva M, Jebara VA, Fabiani JN, et al. Cardiac surgery in patients with human immunodeficiency virus infection. indications and results. J Card Surg 1992;7:240 – 4. 3. Aris A, Pomar JL, Saura E. Cardiopulmonary bypass in HIV-positive patients. Ann Thorac Surg 1993;55:1104 – 8. 4. Flum DR, Tyras DH, Wallack MK. Coronary artery bypass grafting in patients infected with human immunodeficiency virus. J Card Surg 1997;12:98 –101. 5. Cameron DW, Heath-Chiozzi M, Danner S, et al. Randomized placebo-controlled trial of ritonavir in advanced HIV-1 Disease. Lancet; 1998;351:543–9. 6. Henry K, Melroe H, Huebsch J, et al. Severe premature coronary artery disease with protease inhibitors [Letter]. Lancet; 1998;351:1328. 7. Frater RW. As originally published in 1989: human immunodeficiency virus and the cardiac surgeon: a survey of attitudes. Updated in 1999. Ann Thorac Surg 1999; 67:1203– 4. 8. Paone G, Silverman N. Cardiac surgery in patients with HIV Disease. In: Kenneth L. Franco, MD, Ednward D. Verrier, MD, eds. Advanced therapy in cardiac surgery. Hamilton, Ontario: B.C. Decker, 1999:20 – 4.
Closed Chest Bilateral Mammary Artery Grafting in Double-Vessel Coronary Artery Disease Utz Kappert, MD, Romuald Cichon, MD, Jens Schneider, MD, Ina Schramm, MD, and Stephan Schu¨ler, MD, PhD Cardiovascular Institute, University of Dresden, Dresden, Germany
A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease. (Ann Thorac Surg 2000;70:1699 –701) © 2000 by The Society of Thoracic Surgeons Accepted for publication March 6, 2000. Address reprint requests to Dr Schu¨ler, Cardiovascular Institute, University of Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany; e-mail: [email protected].
0003-4975/00/$20.00 PII S0003-4975(00)02007-5