Aortic reconstruction in patients with functioning renal allografts

Patients with functioning renal allografts requiring aortic reconstruction pose a considerable challenge to the vascular surgeon. A variety of strategies for renal allograft preservation during intervention have been described including hypothermia, indwelling shunts, cold renal perfusion, axillofemoral bypass, and endovascular stent-grafting. Reported here are two cases of successful aortic reconstruction utilizing standard open surgical techniques designed simply to minimize warm renal ischemia. The first case was that of a 55 year-old patient with a functional renal allograft originating from the right external iliac artery, who presented acutely with large symptomatic aortic and bilateral iliac artery aneurysms. He was treated with aorto-right femoral/left iliac bypass grafting. The right femoral anastomosis was performed first so that warm renal ischemia was limited to the 34 min required to perform the proximal end-to-end aortic anastomosis. The second case was that of a 44-year-old patient also with a transplanted kidney originating from the right external iliac artery. He presented with worsening hypertension, decreasing renal function, claudication, and severe aortoiliac occlusive disease. He was treated with aorto-left femoral bypass grafting via a retroperitoneal approach, followed by femorofemoral crossover bypass for retrograde perfusion of the kidney (total warm ischemia time 20 min). Both patients recovered uneventfully without a decrement in renal function and remain well on follow-up. It is concluded that standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients, provided warm renal ischemia can be minimized.     

Steroids and bone density in patients with functioning kidney allografts

INTRODUCTION: Osteopenia and osteoporosis after renal transplantation have been associated with factors related to the cause of end-stage renal disease, as well as to clinical events and therapeutic factors in the posttransplant period. We studied the prevalence of low bone density (LBD) according to WHO criteria. METHODS: A cross-sectional study was performed in a cohort of 106 patients (54 men and 52 women) with functioning renal allografts, who underwent bone densitometry (DEXA) of the lumbar spine and femoral neck. Patients were grouped according to DEXA into those with normal bone density (NBD) or LBD. We studied clinical, analytical, and therapeutic variables. RESULTS: Thirtysix patients (34%) had NBD and 70 patients (66%) LBD. Weight was the only parameter showing a significant difference (P = .034), namely, among NBD it was 80.44+/-15.13 versus LBD 73.94 +/- 14.54 kg, respectively. Creatinine clearance (CCr) tended to be lower among patients with LBD 59.62 +/- 22.73 versus 69.59 +/- 28.15 mL/min in patients with NBD (P = .052). PTHi levels were higher in patients with LBD (149.39 +/- 110.75) than those with NBD (110.94 +/- 82.61) (P = .069). In the multivariate analysis the important determinants were weight Exp(ss) = 0.967 [CI = 0.939 to 0.996] (P = .036); CCr Exp(ss) = 0.982 [CI = 0.965 to 1.000] (P = .055); and PTHi levels Exp(ss) = 1.003 [CI = 0.932 to 0.994] (P = .059). CONCLUSIONS: Osteopenia and osteoporosis are frequent among kidney transplant patients (66%), with a similar distribution between the lumbar spine and femoral neck. Excess weight and possibly better renal function may be protective factors. The cumulative steroid dose showed a significant effect on bone density. As expected, secondary hyperparathyroidism in patients with renal impairment seemed to be a risk factor for LBD.     

Cardiac operations in patients with hematologic malignancies.

OBJECTIVES: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.     

Cardiac operations in cirrhotic patients.

It is well recognized that morbidity and mortality rates after cardiac operations with cardiopulmonary bypass in patients with cirrhosis are significantly higher than those in the general cardiac surgical population. Several contributing factors peculiar to cirrhosis, such as compromised nutritional status, increased susceptibility to infections, and impaired coagulopathy, may be responsible for the poor prognosis. It is empirically agreed that cardiac operations using cardiopulmonary bypass are contraindicated in patients with advanced cirrhosis. However, the population of cirrhotic patients who are referred for cardiac operations is still small and definitive indications for surgical interventions remain unknown. Moreover, cirrhotic patients have many distinctive anatomical and physiological features that influence postoperative course considerably. In this article, we reviewed the literature with special reference to its clinical features and clinical outcomes after cardiac surgery that would help cardiac surgeons to decide therapeutic modality. Further understanding of the unique condition, careful patient selection and intensive postoperative care are required to improve the clinical outcome in cirrhotic patients undergoing cardiopulmonary bypass. Recent developments in minimally invasive procedures, such as off-pump coronary artery bypass grafting, however, may enable us to treat patients with advanced cirrhosis safely.     

Cardiac operations in patients with low-grade small lymphocytic malignancies

BACKGROUND: Low-grade small lymphocytic (B cell) malignancies (encompassing chronic lymphocytic leukemia and some types of non-Hodgkin lymphoma) are diseases of the elderly. Open cardiac procedures are known to have increased risk of postoperative infection and other morbidities in these immunodeficient patients. Outcome of open cardiac procedures in these patients was reviewed retrospectively. PATIENTS: Thirteen patients (aged 58-82 years, 11 men, 2 women) with these lymphocytopathologic diseases (8 with chronic lymphocytic leukemia and 5 with non-Hodgkin lymphoma) underwent cardiac operations between January 1977 and June 1998. Mean age was 72 +/- 2.1 years. Isolated coronary artery bypass grafting was performed in 11 and combined procedures and double valve replacement were performed in 1 each. Preoperatively, 9 patients were in a low-risk clinical stage. Mean preoperative duration of lymphocytopathologic disease was 6.1 +/- 1.6 years. Mean preoperative New York Heart Association functional class was 2.8. RESULTS: There was no operative death. Average stay in the intensive care unit was 41.4 +/- 8.6 hours. Postoperative leg and superficial sternal wound infections were encountered in 3 patients. Average postoperative hospital stay was 10.0 +/- 1.7 days. During the follow-up up to 72 months, 1 patient underwent a second cardiac operation. There was 1 late death 4 years later. Coronary stenting was done in 1 patient and a cardioverter-defibrillator was implanted in another patient for recurrent angina. Three patients underwent chemotherapy. Cardiac and lymphocytopathologic status remained stable in others. CONCLUSIONS: Acceptable outcome may be anticipated after cardiac operations in patients with low-grade chronic lymphocytic leukemia and non-Hodgkin lymphoma in early stages. However, the possibility of infection and progression of cardiac and lymphocytopathologic status in these patients should call for caution.     

Cardiac operations in patients with severe pulmonary impairment.

Many reviews concerning pulmonary complications after cardiac surgical procedures in patients with serious pulmonary disease have been published. However, no strict pulmonary function guidelines were proposed to help the clinician identify the patients at greater risk. We considered whether a low pulmonary function became a risk factor of cardiac operations. We conducted a retrospective analysis of records of 32 patients with severely impaired preoperative pulmonary function who had undergone cardiac operations between July 1988 and March 1999. There was 1 hospital death. The over-all mortality rate was 3.1% (1 of 32). However, this death could not be directly attributed to postoperative pulmonary complications. Postoperative pulmonary complications were seen in 2 patients (6.3%) who required tracheostomy due to atelectasis and pneumonia. No late deaths due to pulmonary complications were observed during the follow-up period. The actual survival rate is 68% at 7 years. A low pulmonary function did not, by itself, become a risk factor of cardiac operations, although a pulmonary function test can be used to alert the clinician to possible postoperative complications, including the requirement of tracheostomy. Especially strict control of postoperative respiration is necessary in patients with forced expiratory volume (FEV) of 1.0 <= 800 ml and/or FEV1.0/BSA <= 600 ml/m2.     

Chronic viral hepatitis in renal transplant recipients with allografts functioning for more than 20 years

BACKGROUND: The impact of infection with hepatotropic viruses (hepatitis B virus [HBV] and hepatitis C virus [HCV]) on morbidity and mortality, and allograft function in renal transplant recipients with allografts functioning for >20 years is not known. METHODS AND RESULTS: Seventy-nine of 511 renal transplants performed at the Cleveland Clinic Foundation from January 1963 to January 1978 are known to have functioned for at least 20 years (level 5A). Fifty-four of these patients had hepatitis testing updated after their 19th year of transplantation. Fifteen patients had evidence of ongoing viral infection: persistent hepatitis B surface antigen in three (6%), HCV antibody (enzyme-linked immunosorbent assay II supplemented by recombinant immunoblot assay) in 11 (20%), and both viruses in one (2%). Of the 10 surviving patients, 8 were tested further for viral replication. HCV RNA (polymerase chain reaction; Amplicore) was positive in 6/7 (86%), and HBV DNA (hybridization) was positive in 1/2 (50%). An elevated alanine aminotransferase (>35 U/L) was present in all hepatitis patients, alpha-fetoprotein >10 ng/ml in 2/8 (25%), and cryoglobulins >50 microg/ml in 3/6 (50%) infected with HCV. No hepatocellular carcinoma was detected by hepatic ultrasound. In patients with chronic viral hepatitis, probable cirrhosis developed in 20% (3/15) compared to one patient in the group without hepatitis, but there was no mortality from liver failure in either group. Diabetes mellitus was significantly more common in those with than without hepatitis (11/15 vs. 10/39; P=0.002), but severe infection was not (9/15 vs. 15/39). Five hepatitis patients (33%) have died of non-hepatic causes (one from meningitis, one from unknown cause, and three from coronary heart disease [CHD] vs. only two individuals without hepatitis [5%]; P= 0.014). Although the more frequent occurrence of CHD among those with hepatitis was not significant (7/15 vs. 8/39; P=0.09), CHD as a cause of death in those with HCV was significantly increased (P=0.03). CONCLUSIONS: Twenty-year renal transplant recipients infected with hepatotropic viruses (HBV and HCV) have a high rate of active viral replication (88%), a greater frequency of diabetes (P=0.01), and a higher overall mortality (P=0.014).     

Cardiovascular operations in patients with dialysis-dependent renal failure.

BACKGROUND: Cardiac operations in patients with end-stage renal disease carry a significantly increased perioperative risk, and long-term functional results and survival are still purely defined. METHODS: Therefore, we performed a retrospective analysis of 45 consecutive patients with dialysis-dependent renal failure who underwent either coronary artery bypass grafting (n = 30), valve replacement or combined procedures (n = 13), or pericardiotomy (n = 2). Mean age of the patients was 59+/-10 years. RESULTS: There were two perioperative deaths (30-day mortality, 4.4%). Actuarial survival rates at 1, 2, 3, and 5 years were 0.90, 0.73, 0.67, and 0.67, respectively, after bypass operation and 0.77, 0.77, 0.77, and 0.39, respectively, after valvular or combined operation. Late deaths (n = 13) occurred 2 to 60 months after operation and were attributable to cardiac events in 7 patients. Of the long-term survivors after either bypass grafting (n = 20) or a valvular or combined procedure (n = 8), 15 and 7 patients had improved anginal status and New York Heart Association functional status, respectively, after 36+/-4 months (range, 21 to 66 months). Five patients underwent renal transplantation 32+/-9 months after cardiac operation. CONCLUSIONS: Cardiac operations in patients with endstage renal disease may be performed with a fairly low perioperative risk and the perspective of long-term functional improvement and acceptable long-term survival.     

Cardiac surgery in patients with chronic renal disease

The combination of chronic renal failure and cardiovascular disease is identified frequently and results in high morbidity and mortality without appropriate medical and surgical therapy. Experience during the last eighteen years has shown that cardiac operations can be undertaken in this high-risk group with acceptable morbidity and mortality and with reasonable expectation of symptomatic improvement. In a six-year period, 17 patients with chronic renal disease underwent cardiac procedures at the Vanderbilt University Affiliated Hospitals. Ten patients were on long-term hemodialysis, and 7 had a functioning renal transplant. Thirteen patients had a coronary artery bypass procedure alone, 1 had a bypass procedure plus aortic valve replacement, 1 had a bypass procedure plus repair of the mitral valve, 1 had a bypass procedure and resection of a left ventricular aneurysm, and 1 had aortic valve and mitral valve replacement for endocarditis. Sixteen patients survived and were discharged. The hospital stay was shorter for patients with a renal transplant than for those on hemodialysis (mean, 11 days versus 22 days, respectively), and perioperative complications were less frequent in the transplant group. There has been 1 late death unrelated to the operative procedure. Fifteen long-term survivors have been followed a mean of 26 months (range 7 to 108 months). All have achieved symptomatic improvement and are in New York Heart Association Functional Class I or II. These results in this high-risk patient group provide a basis for cautious optimism and for a continued aggressive approach in patients with chronic renal disease who require cardiac operation.     

Cardiac surgery in patients with end-stage renal disease

Objectives: The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients.Methods: These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months.Results: Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred.Conclusions: Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.     

Cardiac surgery in patients with end-stage renal disease

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 (9:1), number of vessels bypassed per patient (2.4), 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.     

Cardiac surgery in patients with dialysis-dependent renal disease.

This study was designed to evaluate the operative outcome of dialysis patients undergoing cardiac surgery. A retrospective review was performed of 28 consecutive patients with end-stage renal disease dependent on maintenance hemodialysis (n = 26) or peritoneal dialysis (n = 2) who underwent cardiopulmonary bypass (CPB). The operations included isolated coronary artery bypass grafting (CABG) (n = 21), aortic valve replacement (n = 4) and CABG plus aortic valve replacement (n = 3). Seven operations were emergent or urgent. In 23 patients, a heparin-coated (HC) circuit with reduced systemic heparinization was used for CPB. The hospital mortality was 7.1%. Complications occurred in 13 patients (46%). Although thoracotomy for bleeding was required in 3 patients, only 1 had undergone CPB with an HC circuit. There were 7 late deaths. All survivors showed improvement in symptoms and overall functional status. The actuarial survival rates were 78% and 58% at 1 and 4 years, respectively. In the 10 patients with diabetes mellitus, the 4-year survival rate was 50%. In the patients who underwent non-elective surgery, the survival rate was 29%. Cardiac surgery can be performed with increased but acceptable mortality in dialysis patients. Good symptomatic relief can be expected. Surgery should be performed before the general condition deteriorates.     

Cardiac operations in patients over 80 years of age

Twenty-five patients between 80 and 89 years of age underwent a variety of cardiac surgical procedures. Operative mortality was 4%. Perioperative complications were frequent and resulted in an increased hospital stay postoperatively (mean 19.5 days). At a mean follow-up of 29.1 months, 21 patients (84%) are alive, with improvement in functional class from 3.4 to 2.0 (p less than 0.005). Cardiac operations can be performed in patients over 80 years of age with low mortality and significant symptomatic benefit. A high incidence of complications necessitates careful monitoring but should not represent a contraindication to the surgical management of advanced heart disease in this group.