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Ann Thorac Surg 2000;69:96-101
© 2000 The Society of Thoracic Surgeons

Original Articles

Cardiac surgery in patients with end-stage renal disease: 10-year experience

Michael Horst, MDa, Uwe Mehlhorn, MD, PhDa, Simon P. Hoerstrup, MDa, Michael Suedkamp, MDa, E. Rainer de Vivie, MD, PhDa

a Clinic for Cardiothoracic Surgery, University of Cologne, Cologne, Germany

Address reprint requests to Dr Horst, Department of Cardiac Surgery, Staedt Kliniken gGmbH, Dr.-Eden-Str 10, 26133 Oldenburg, Germany


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. End-stage renal disease is known to be an important risk factor complex for cardiac operations performed with cardiopulmonary bypass.

Methods. To investigate the influence of preoperative status on perioperative mortality and morbidity, we retrospectively analyzed data from 65 patients (20 women and 45 men with a mean age of 58.8 ± 10.0 years [± standard deviation]) with end-stage renal disease who were on dialysis and who underwent a cardiac surgical procedure between 1988 and 1998.

Results. Fifty-one percent of the patients had isolated coronary artery bypass grafting, 35% had replacement or reconstruction of one valve or two valves, and 14% underwent combined coronary artery bypass grafting and valve replacement. The perioperative mortality rate was 13.8% with 78% (7 of 9) of deaths occurring in patients having a valve procedure. Six of the 9 patients who died had compromised left ventricular function preoperatively, and all 9 were in New York Heart Association class III or IV. Mean preoperative duration of dialysis was longer (80 ± 70 months) in the 9 patients who died compared with that in the surviving 56 patients (45 ± 49 months) (p = 0.05). We found dyspnea at rest, duration of dialysis of 60 months or more, combined procedures (coronary artery bypass grafting and valve operation), and New York Heart Association class IV to be associated with a higher relative risk for perioperative death. Neither angina pectoris nor isolated coronary artery bypass grafting was associated with increased relative risk for perioperative death. However, after a cardiac operation, mortality in patients with end-stage renal disease was substantially higher than in those with normal renal function.

Conclusions. These data are comparable with those in the literature and possibly suggest that both indications and referral for surgical intervention have been delayed in patients who have end-stage renal disease combined with coronary artery disease, valve disease, or both. The delay may contribute to the relatively high perioperative mortality.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Patients with end-stage renal disease (ESRD) requiring cardiac surgical intervention represent a nonhomogeneous population in terms of etiology of ESRD, underlying cardiac disease (ie, coronary artery disease, cardiac valve disease, or both), duration of dialysis at the time of operation, and comorbidity. Cardiovascular diseases and cardiac complications are the major causes of death in patients with ESRD [1, 2]. The risk of acute myocardial infarction, angina pectoris, or pulmonary edema associated with left ventricular (LV) failure is as high as 10% per year, and the incidence of sudden cardiac death, congestive heart failure, ischemic heart disease, and complex ventricular arrhythmias has been reported to be 9%, 10%, 17% to 31%, and 18%, respectively [1, 3]. Congestive heart failure secondary to dilated cardiomyopathy, hypertrophic hyperkinetic disease, and ischemic heart disease as well as calcification of myocardial structures including the valves are important complications associated with ESRD [4, 5]. For example, the cumulative 2-year survival rate for patients with ESRD and congestive heart failure has been reported to be as low as 33% [4].

At the time of initiation of dialysis, 19% of patients have severe LV hypertrophy. Only 23% of patients with ESRD show regular cardiac function as determined by echocardiography [3]. Factors associated with ESRD such as anemia, hypertension, volume overload, or presence of an arteriovenous shunt can lead to intravascular sound phenomena that can mask cardiac valve diseases [6]. In addition, uremic polyneuropathy can mask angina pectoris symptoms as does diabetic polyneuropathy [7]. The increased calcium-phosphate product caused by secondary hyperparathyroidism results in calcifications in multiple organs [5, 6, 8]. Specifically, accelerated atherosclerosis and calcification of cardiac structures including valves and conduction tissue are thought to be due to secondary hyperparathyroidism in ESRD [9].

As a consequence, ESRD is known to be an important risk factor complex for patients undergoing a cardiac operation on cardiopulmonary bypass (CPB). Specifically, CPB–associated problems such as fluid and electrolyte balance, hemoglobin concentration, and hemostasis necessitate optimal perioperative management of patients with ESRD.

Both knowledge and consideration of the risk factors associated with ESRD are necessary to optimize clinical outcome after a cardiac surgical procedure in these patients. The aim of this retrospective study was to determine the impact of preoperative clinical status on perioperative morbidity and mortality in patients with ESRD undergoing a cardiac operation.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient population
We retrospectively analyzed the charts of 65 patients (20 women and 45 men) with ESRD who were on dialysis and who underwent a cardiac surgical procedure with CPB between 1988 and 1998 at our institution. The causes of renal failure are shown in Table 1. All patients accepted for an elective operation underwent dialysis on the day prior to operation, and all patients had intraoperative hemofiltration on CPB. The target value for perioperative hemoglobin concentration was 10 g/dL or higher. For myocardial protection, patients received antegrade hypothermic (4°C) crystalloid Bretschneider cardioplegia, and CPB was performed at moderate systemic hypothermia (25° to 32°C). Postoperatively, dialysis was commenced after hemodynamic stabilization in all patients.


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  		Table 1. Causes of End-Stage Renal Diseasea

 
Mean patient age at the time of operation was 58.8 ± 10.0 years (range, 32 to 79 years). Women were older (mean age, 63.9 ± 8.8 years; range, 48 to 79 years) than men (mean age, 56.5 ± 9.7 years; range, 32 to 78 years) (p = 0.01). Hemodialysis was performed in 57 patients and peritoneal dialysis, in 8 patients. Mean preoperative duration of dialysis was 49.8 ± 53.4 months (range, 1 to 193 months), and preoperative creatinine level was 8.2 ± 2.8 mg/dL (range, 3.4 to 16.0 mg/dL). The mean preoperative hemoglobin concentration was 10.3 ± 1.7 g/dL (range, 6.9 to 14.1 g/dL).

At the time of operation, 54% of the patients had moderate or severe LV dysfunction (LV ejection fraction < 0.50 and LV end-diastolic pressure > 14 mm Hg), 74% had dyspnea (31% at rest), and 68% had angina pectoris. Of the patients, 91% were in New York Heart Association (NYHA) class III (n = 35) or IV (n = 23), and 55% required urgent or emergent operation. The preoperative patient data are summarized in Table 2. In addition, the patients exhibited substantial comorbidity, especially peripheral arterial vascular disease, chronic obstructive pulmonary disease, and neurologic disorders.


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  		Table 2. Preoperative Status of Patients With End-Stage Renal Diseasea

 
Statistical analysis
Data are presented as the mean ± the standard deviation and were analyzed using two-tailed t test for independent continuous scale data and Mann-Whitney U test for nonparametric data where appropriate. A p value of 0.05 or less was considered significant. To estimate the importance of an individual variable with respect to perioperative mortality, we derived the relative risk using the equation relative risk=presence of the individual variable (%)/absence of the individual variable (%). Thus, a relative risk of 1.0 represents no additional risk for perioperative death in patients with ESRD.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Figure 1 shows the distribution of cardiac operations in patients with ESRD performed per year between January 1988 and March 1998 at our institution. After an initial increase from 1988 to 1992, the number of cardiac operations performed annually in these patients reached a plateau of about eight to ten per year.



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  		Fig 1. Annual cardiac operations in patients with end-stage renal disease (ESRD) performed between January 1988 and March 1998 at the University of Cologne.

 
Of the patients with ESRD, 51% underwent isolated coronary artery bypass grafting (CABG) with a mean of 3.5 ± 1.4 distal anastomoses (range, one to seven anastomoses), 35% had replacement or reconstruction of one or two valves, and 14% underwent CABG and valve replacement (Table 3). In the patients having isolated CABG, the left internal mammary artery was used in 73% (24/33) and in the patients having combined procedures (CABG plus valve operation), that artery was used in 22% (2/9). The right internal mammary artery was not used in any patient. We implanted 40 valves (11 biological Medtronic Intact valves and 29 mechanical St. Jude Medical bileaflet valves) in 30 of our 65 patients.


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  		Table 3. Operative Procedures and Perioperative Mortality

 
Mean CPB duration was 130 ± 60 minutes (range, 29 to 329 minutes), mean aortic cross-clamp time was 70 ± 30 minutes (range, 8 to 170 minutes), and mean duration of the surgical procedure was 238 ± 84 minutes (range, 130 to 570 minutes). Postoperative duration of mechanical ventilation was 1.8 ± 2.4 days (range, 0 to 14 days), and total stay in the intensive care unit was 3.2 ± 2.9 days (range, 0 to 14 days).

The perioperative mortality rate was 13.8% (9/65), which is substantially higher than the 3.4% for all cardiac operations on adults performed, with CPB between January 1988 and March 1998 at our institution. Seven (78%) of the nine deaths occurred in patients having a valve procedure (see Table 3). Six of the 9 patients who died had compromised LV function before operation, and 4 of the 9 were in NYHA class III and 5, in NYHA class IV. Mean preoperative duration of dialysis was longer (80 ± 70 months) in the 9 patients who died compared with that in the surviving 56 patients (45 ± 49 months) (p = 0.05).

The duration of dialysis before operation for the group having isolated CABG, the group having an isolated valve procedure, and the group with combined procedures was 39.1 ± 45.7 months (range, 1 to 183 months), 54.2 ± 51.6 months (range, 1 to 183 months), and 78.3 ± 75.5 months (range, 3 to 193 months), respectively. There were no significant differences between groups.

Perioperative complications in survivors and those who died are shown in Table 4. The main complications were low cardiac output syndrome (14%), postoperative hemorrhage caused by coagulation disturbances (11%), cardiac arrhythmias (11%), and perioperative myocardial infarction (8%). Repeat thoracotomy was necessary in 7 patients (11%). Four patients (6%) had infections: among the surviving patients, 1 had sinusitis and the other, a local subcutaneous presternal wound infection that did not require repeat thoracotomy; in the group of patients who died, 2 had pneumonia leading to sepsis. None of the patients had development of mediastinitis. Overall, 48 complications were registered in the 65 patients, 50% of them occurring in the 13.8% of patients who died.


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  		Table 4. Perioperative Complications

 
Table 5 shows the relative risk for perioperative death calculated for 16 variables. Dyspnea at rest, duration of dialysis for 60 months or longer, combined procedures (CABG and valve operation), and NYHA class IV were associated with a high relative risk for perioperative death. Angina pectoris and isolated CABG were not associated with increased relative risk for perioperative death in patients with ESRD. Compared with isolated CABG, the relative perioperative mortality risk associated with cardiac valve procedure and CABG plus valve procedure for patients with ESRD was five times and ten times higher, respectively.


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  		Table 5. Relative Risk for Perioperative Death

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The data from this retrospective analysis show that our patients with ESRD seen for a cardiac surgical procedure exhibited a substantial risk profile with respect to both cardiac and noncardiac comorbidity (see Table 2). Specifically, looking at the group comprising all cardiac valve procedures in ESRD patients, we found a higher relative risk for perioperative death than in the group with isolated CABG. If a combined cardiac procedure (ie, CABG and valve operation) was performed, the relative risk for perioperative death was about ten times that of isolated CABG. In addition, we found the preoperative factors dyspnea at rest, duration of dialysis equal to or longer than 60 months, and NYHA class IV to be associated with substantially increased relative risk for perioperative death. In contrast, isolated CABG was not associated with increased relative perioperative mortality risk in one patient with ESRD (see Table 5).

Even though this analysis appears to be limited because of the relatively small number of patients, our results are consistent with those from other institutions. An overview of the available literature summarizing results for 863 patients over 30 years shows the perioperative mortality rate for isolated CABG, isolated cardiac valve operation, and combined procedures to be 8.9%, 19.3%, and 39.5%, respectively (Table 6). In addition, the calculated relative risks for perioperative death in these ESRD patients undergoing isolated CABG, isolated cardiac valve procedure, and combined procedures are 0.4, 1.8, and 3.5, respectively, which are similar to the estimated relative risks of 0.3, 1.5, and 3.1, respectively, in our patients. These data suggest that patients with ESRD who are seen for a valve operation may be in worse condition than those with isolated coronary artery disease. Although 54% of our patients had compromised LV function and 91% were in NYHA class III or IV, we did not find differences between patients having a valve operation and those undergoing isolated CABG with respect to these variables. However, absolute perioperative mortality associated with a cardiac procedure was substantially higher in patients with ESRD than in patients with normal renal function.


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  		Table 6. Thirty-Year Literature Overview of Perioperative Mortality Rates for Patients With End-Stage Renal Disease Undergoing Cardiac Operation With Cardiopulmonary Bypassa

 
The available 30-year experience of the combined institutions shows an overall perioperative mortality rate of 12.5% for ESRD patients undergoing a cardiac surgical procedure with CPB, which is comparable to the 13.8% in our study. The perioperative mortality rate at the eight institutions where fewer than 20 surgical procedures were performed was 23.7% in 118 patients compared with 10.7% in 745 patients at the 12 centers where more than 20 were done (see Table 6). Thus, even in "experienced" cardiac surgical institutions, mortality for patients with ESRD is still substantially higher than for patients with normal renal function.

Several factors possibly contribute to this high mortality. Most patients with renal insufficiency demonstrate LV hypertrophy and subsequent subendocardial ischemia secondary to arterial hypertension even prior to ESRD requiring dialysis [3]. In addition, ESRD can cause LV dysfunction through toxic effects. This is supported by Foley and Parfrey [2], who found in a prospective 10-year study involving 433 patients with ESRD that renal transplantation dramatically improved LV abnormalities. Their finding suggests a uremic environment is cardiotoxic. Another important factor is hyperparathyroidism secondary to renal failure, which has been shown to be associated with accelerated atherosclerosis and calcification of cardiac structures including valves and conduction tissue [9]. In addition, factors associated with ESRD can mask clinical symptoms [6, 7]. Specifically, it has been reported that even in the presence of substantial coronary artery disease, patients with ESRD have little or no anginal pain, which is probably the result of diabetic or uremic polyneuropathy or both [29]. Hässler and colleagues [7] reported that in 100 patients with ESRD undergoing coronary angiography, the coronary artery disease would not have been detected in 48% of the patients had angina pectoris been the sole criterion. Even a coronary stenosis of greater than 90% would have been overlooked in 30% of these patients [7].

Potential underestimation of cardiac valve disease is even more evident in patients with ESRD. Renal anemia, arterial hypertension, volume overload, or the presence of an arteriovenous shunt can lead to intravascular sound phenomena that can mask cardiac valve disease [6]. In addition, typical symptoms of progressive valve disease such as congestion and effusions can be concealed by dialysis, thus making timely diagnosis of potential cardiac decompensation more difficult [7]. Further, Hässler and associates [7] found that cardiac valve disease as determined by valve calcification progresses with the duration of dialysis; this is thought to be due mainly to secondary hyperparathyroidism [6].

These data suggest that both indications and referral for operation can be delayed in patients with ESRD who have coronary artery disease, valve disease, or both and that this may contribute to the high perioperative mortality in these patients. This is supported by the fact that 55% of our patients with ESRD underwent urgent or emergent cardiac surgical intervention and that 6 of the 9 patients who died had urgent or emergent operation. We believe that patients with ESRD require screening at short-term intervals using noninvasive techniques such as Doppler ultrasonography and echocardiography to detect cardiac deterioration prior to decompensation. This could result in earlier referral for cardiac surgical intervention and might reduce perioperative mortality and morbidity [10, 16, 27].

Both knowledge and consideration of these factors could help optimize perioperative management and potentially improve clinical outcome in the nonhomogeneous group of patients with ESRD who undergo CABG, cardiac valve operation, or both on CPB. This appears to be even more important because of the increasing number of patients requiring dialysis and hence, a cardiac surgical procedure [30]. However, prospective studies involving the close collaboration of nephrologists, cardiologists, and cardiac surgeons are required to prove that more aggressive screening and earlier referral for a cardiac operation will, in fact, decrease perioperative mortality and morbidity in these patients.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. US Renal Data System 1991 annual data report. Am J Kidney Dis 1991;18(Suppl 2)1–127.
  2. Foley R.N., Parfrey P.S. Cardiac disease in chronic uremia. Adv Ren Replace Ther 1997;4:234-248.[Medline]
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Accepted for publication June 12, 1999.




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E. Prifti, M. Bonacchi, M. Leacche, G. Frati, G. Giunti, P. Proietti, A. M. Cricco, G. Brancaccio, B. Furci, A. Baboci, et al.
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How to diagnose and treat coronary artery disease in the uraemic patient: an update
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 CirculationHome page
J. Y. Liu, N. J. O. Birkmeyer, J. H. Sanders, J. R. Morton, H. F. Henriques, S. J. Lahey, R. W. Dow, C. Maloney, A. W. DiScipio, R. Clough, et al.
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 J. Thorac. Cardiovasc. Surg.Home page
G. Segarra, P. Medina, J. M. Vila, J. B. Martinez-Leon, R. M. Ballester, P. Lluch, and S. Lluch
Contractile effects of arginine analogues on human internal thoracic and radial arteries
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E. Rainer de Vivie
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