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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 6  |  Page : 1157-1164
Cardiac surgery in patients on hemodialysis: Eight years experience of the Tunisian military hospital

Department of Anesthesia and Intensive Care, Tunisian Military Hospital, Tunis, Tunisia

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Date of Web Publication4-Nov-2010


End-stage renal disease (ESRD) is known to be an important risk factor for cardiac operations performed with cardiopulmonary bypass. We investigated the influence of preoperative status on perioperative mortality and morbidity. We retrospectively analyzed data from 26 patients with ESRD, who were on maintenance dialysis and underwent a cardiac surgical procedure bet­ween 2000 and 2007. Of them, 61.5% of the patients had isolated coronary artery bypass grafting (CABG) and 38.5% had replacement or reconstruction of one or two valves. The perioperative mortality rate was 26% with five deaths occurring in patients undergoing CABG procedure. We found CABG procedure, being female and left ventricular (LV) function < 30% to be associated with a higher relative risk for perioperative death. In conclusion, our data suggest that both indi­cations and referral for surgical intervention for coronary artery disease may be delayed in pa­tients who have ESRD, contributing to the relatively high perioperative mortality.

How to cite this article:
Gharsallah H, Trabelsi W, Hajjej Z, Nasri M, Lebbi A, Jebali MA, Ferjani M. Cardiac surgery in patients on hemodialysis: Eight years experience of the Tunisian military hospital. Saudi J Kidney Dis Transpl 2010;21:1157-64

How to cite this URL:
Gharsallah H, Trabelsi W, Hajjej Z, Nasri M, Lebbi A, Jebali MA, Ferjani M. Cardiac surgery in patients on hemodialysis: Eight years experience of the Tunisian military hospital. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Oct 18];21:1157-64. Available from: https://www.sjkdt.org/text.asp?2010/21/6/1157/72317

   Introduction Top

Patients with chronic kidney disease on main­tenance dialysis requiring cardiac surgical in­tervention represent a non-homogeneous popu­lation in terms of etiology of end-stage renal failure (ESRF), underlying cardiac disease (i.e., coronary artery disease, cardiac valve disease, or both), duration of dialysis at the time of ope­ration and comorbidity. They often have asso­ciated disorders that predispose them to in­creased operative morbidity and mortality, such as inability to excrete certain medications, plate­let dysfunction and susceptibility to infection.

Cardiovascular diseases and cardiac compli­cations are the major causes of death in pa­tients with ESRF. [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, 17-31 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 chronic renal failure requiring hemodialysis (HD). [4],[5] At the time of initiation of dialysis, 19% of patients have severe LV hypertrophy. Only 23% of patients on HD show regular car­diac function. [3] In addition, uremic polyneuro­pathy can mask angina pectoris symptoms as does diabetic polyneuropathy [6] The increased calcium-phosphate product caused by secondary hyperparathyroidism results in calcifications in multiple organs. [5],[7],[8] Specifically, accelerated atherosclerosis and calcification of cardiac struc­tures including valves and conduction tissue are thought to be due to secondary hyperpara­thyroidism in end-stage renal disease (ESRD). [9] As a consequence, ESRD is known to be an important risk factor complex for patients un­ dergoing 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 HD.

The aim of this retrospective study was to determine the impact of preoperative clinical and biological status on perioperative morbi­dity and mortality in patients on maintenance HD, undergoing a cardiac surgery.

   Patients and Methods Top

Population studied

After getting approval from the local ethics co­mmittee, consent was obtained from the patients and retrospective analysis of the data was done of 26 patients (18 men and 8 women) on main­tenance HD and undergoing a cardiac surgical procedure with CPB, between 2000 and 2007 at our institution. The causes of renal failure are shown in [Table 1].
Table 1 :Causes of chronic renal failure.

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All the patients accepted for an elective ope­ration underwent dialysis on the day prior to operation and all of them 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 (4ºC) crystalloid Bretschneider cardioplegia and CPB was performed at moderate systemic hypother­mia (33ºC). Postoperatively, dialysis was started after hemodynamic stabilization in all patients.

Mean patient age at the time of operation was 61 ± 10 (38-79) years. Mean preoperative du­ration of dialysis was 24.7 ± 27 (4-132) months and preoperative creatinine level was 400.5 ± 153.2 μmol/L (range: 142-570 mg/dL). The mean preoperative hemoglobin concentration was 9.65 ± 1.21 (7.7-12.2) g/dL.

At the time of operation, 7.5% of the patients had severe LV dysfunction (LV ejection frac­tion < 30%) and NYHA status was ≥III in 70% (9 cases of NYHA III and 9 cases of NYHA IV). No patients in our data required urgent or redo operation. The mean EUROSCORE was 8.46 ± 2.7 with a predicted mortality of 13.6 ± 12.18%.

The preoperative patient data are summarized in [Table 2]. In addition, the patients exhibited substantial comorbidity, especially diabetes me­llitus, arterial hypertension, history of smoking and obesity.
Table 2 :Preoperative status of patients.

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   Statistical Analysis Top

Data were presented as the mean ± the stan­dard deviation and were analyzed using two­tailed 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

The distribution of cardiac operations in pa­tients with ESRD performed per year between 2000 and 2007 at our institution is shown in [Figure 1]. 61.5% of our study patients under­went isolated coronary artery bypass grafting (CABG) with a mean of 2.69 ± 0.87 distal anastomosis (range: one to four anastomosis), 38.5% had replacement or reconstruction of one valve, and none underwent combined CABG and valve replacement [Table 3]. In the patients undergoing isolated CABG, the left internal mammary artery was used in 97% of cases (25/26). Blood transfusions required an average of 3.5 ± 1.5 units of packed red blood cells per patient.
Table 3 :Operative procedures and perioperative mortality.

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Figure 1 :Evolution of numbers of patients included in the study per year.

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Mean CPB duration was 126 ± 43 (29-329) minutes, mean aortic cross-clamp time was 81 ± 34 (8-170) minutes and mean duration of the surgical procedure was 256 ± 184 (178-465) minutes. Postoperative inotropics were neces­sary in 10/26 patients (38.5%); three of these patients died.

Postoperative prolonged mechanical ventila­tion (>24 hours) was 15.4% with a mean of 7.5 ± 10.35 days (range: 2-23 days). Total stay in the intensive care unit and in the hospital were 4.35 ± 3.5 days (0-23 days) and 14.85 ± 5.93 days (6-33 days), respectively. The postopera­tive mortality rate was 26% (6/26). Four (66.6%) of the six deaths occurred in patients undergoing a CABG procedure. The two pa­tients who had compromised LV function be­fore operation died and two of the six patients were in NYHA class II, three were in NYHA class III and one was in NYHA class IV. The duration of dialysis before operation for the group having isolated CABG and the group having an isolated valve procedure was 23.5 ± 30.5 months (4-132 months) and 27.1 ± 26.6 months (7-72 months), respectively(P = 0.42).

Mean preoperative duration of dialysis in the six patients who died (20 ± 9.8 months; range: 12-36 months) compared with that in the surviving 20 patients (26.15 ± 30.4 months; range: 4-132 months) was not different (P = 0.65).

Perioperative complications in survivors and those who died are shown in [Table 4]. The main complications were cardiac arrhythmias (37.5%), perioperative myocardial infarction (21%) and low cardiac output syndrome (8.3%). Four pa­tients (6%) had subcutaneous pre-sternal wound infection among the surviving patients. In the group of patients who died, two had pneumo­nia leading to sepsis. Overall, 24 complications were registered in the 26 patients, 25% of them occurring in the 26% of patients who died.
Table 4 :Perioperative complications.

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[Table 5] shows the relative risk for periope­rative death calculated for 11 variables.
Table 5 :Relative risk for perioperative death.

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   Discussion Top

The data from this retrospective analysis shows that our patients with ESRD, seen for a cardiac surgical procedure, exhibited a substantial risk profile with respect to both cardiac and non­cardiac comorbidity [Table 2]. Specifically, loo­king at the group comprising isolated CABG, we found a higher relative risk for periopera­tive death than in the group with cardiac valve procedures. In addition, we found the preopera­tive factors like compromised LV function, fe­male and NYHA class IV to be associated with substantially increased relative risk for peri­operative death.

This analysis appears to be limited because of the relatively small number of patients. How­ever, our results are not similar to those from other institutions [Table 6]. Horst et al [10] showed, in an overview of literature summarizing re­sults for 863 patients over 30 years, the peri­operative mortality rate for isolated CABG and isolated cardiac valve operation to be 8.9 and 19.3%, respectively. In addition, the calculated relative risks for perioperative death in these ESRD patients undergoing isolated CABG, isolated cardiac valve procedure were 0.4 and 1.8, respectively, which are opposed to the esti­mated relative risks of 1.3 and 0.3, respectively, in our patients. These data suggest that patients with ESRD with isolated coronary artery di­sease may be in worse condition than those who are seen for a valve operation. The avai­lable 30-year experience of the combined ins­titutions [10] shows an overall perioperative mor­tality rate of 12.5% for ESRD patients under­going a cardiac surgical procedure with CPB, which is twice lower than the 26% in our study.
Table 6 :Forty-year literature overview of perioperative mortality rates for patients with end-stage renal disease, undergoing cardiac operation with cardiopulmonary bypass.

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In addition, 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 procedures were performed. Thus, even in "ex­perienced" cardiac surgical institutions, morta­lity for patients with ESRD is still substan­tially higher than for patients with normal re­nal function (which is the case of our institution).

Several factors possibly contribute to this high mortality. Most patients with renal insuf­ficiency demonstrate LV hypertrophy and sub­sequent sub-endocardial ischemia secondary to arterial hypertension even prior to ESRD re­quiring dialysis. [4] In addition, ESRD can cause LV dysfunction through toxic effects. This is supported by Foley and Parfrey, [3] who found in a prospective ten-year study involving 433 pa­tients with ESRD that renal transplantation dramatically improved LV abnormalities. Their finding suggests that uremic environment is cardiotoxic. Another important factor is secon­dary hyperparathyroidism in ESRD patients, which has been shown to be associated with accelerated atherosclerosis and calcification of cardiac structures including coronary arteries, 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. [11] Hassler 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 evident in patients with ESRD Renal anemia, arterial hypertension, volume overload, or the presence of an arteriovenous shunt can lead to intravascular sound phenol­mena 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 [6] Further, Hassler and associates [6] 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. 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. [12],[13],[14] This appears to be even more important because of the increa­sing number of patients requiring dialysis and hence, a cardiac surgical procedure. [15]

In conclusion, optimization of perioperative management and clinical outcome of patients with ESRD who undergo CABG, cardiac valve operation, or both on CPB can improve with the better understanding of the associated risk factors. This could help in timely referral to the cardiac surgeon, thus reducing the periope­rative risks. Small numbers and its retrospect­tive nature have limited our study and we would like to undertake further work with longer fol­low-up and quality of life assessment, as the long-term benefits of cardiac surgery in dia­lysis-dependent patients are yet to be fully es­tablished.[30]

   References Top

1.US Renal Data System 1991 annual data re­port. Am J Kidney Dis 1991;18(Suppl 2):1-127.  Back to cited text no. 1
2.Foley RN, Parfrey PS. Cardiac disease in chronic uraemia: Clinical outcome and risk factors. Adv Ren Replace Ther 1997;4(3):234-48.  Back to cited text no. 2
3.Parfrey PS, Harnett JD, Barre PE. The natural history of myocardial disease in dialysis patients. J Am Soc Nephrol 1991;2(1):2-12.  Back to cited text no. 3
4.Parfrey PS, Griffiths SM, Harnett JD. Outcome of congestive heart failure, dilated cardiomyo­pathy, hypertrophic hyperkinetic disease, and ischemic heart disease in dialysis patients. Am J Nephrol 1990;10(3):213-21.  Back to cited text no. 4
5.Rostand SG, Sanders C, Kirk KA, Rutsky EA, Fraser RC. Myocardial calcification and car­diac dysfunction in chronic renal failure. Am J Med 1988;85(5):651-7.  Back to cited text no. 5
6.Hassler R, Ho¨ fling B, Castro L, et al. Coro­nary heart disease and heart valve diseases in patients with terminal kidney insufficiency. Dtsch Med Wochenschr 1987;112(18):714-8  Back to cited text no. 6
7.Braunwald E. Heart disease: A textbook of cardiovascular medicine. 5th ed. Philadelphia. WB Saunders, 1997. 1923-38.  Back to cited text no. 7
8.Henderson RR, Santiago LM, Spring DA, Harrington AR. Metastatic myocardial calcifi­cation in chronic renal failure presenting as atrioventricular block. N Engl J Med 1971;284 (22):1252-3.  Back to cited text no. 8
9.Jain M, D'Cruz I, Kathpalia S, Goldberg A. Mitral annulus calcification as a manifestation of secondary hyperparathyroidism in chronic renal failure. Circulation 1980;62(Suppl):133.  Back to cited text no. 9
10.Horst M, Uwe M, Hoerstrup SP. Cardiac surgery in patients with end-stage renal disease: 10-year experience. Ann Thorac Surg 2000;69(1):96-101.  Back to cited text no. 10
11.Bennet WM, Kloster F, Rosch J, Barry J, Porter GA. Natural history of asymptomatic coronary arteriographic lesions in diabetic patients with end-stage renal disease. Am J Med 1978;65(5):779-85  Back to cited text no. 11
12.Ko W, Kreiger KH, Isom OW. Cardiopulmo­nary bypass procedures in dialysis patients. Ann Thorac Surg 1993;55(3):677-84.  Back to cited text no. 12
13.Kaul TK, Fields BL, Reddy MA, Kahn DR. Cardiac operations in patients with end-stage renal disease. Ann Thorac Surg 1994;57(3): 691-6.  Back to cited text no. 13
14.Nakayama Y, Sakata R, Ueyama K, et al. Car­diac surgery in patients with chronic renal failure on maintenance dialysis. Nippon Kyobu Geka Gakkai Zasshi 1997;45(10):1661-6.  Back to cited text no. 14
15.Koyanagi T, Nishida H, Kitamura M, et al. Comparison of clinical outcomes of coronary artery bypass grafting and percutaneous trans­luminal coronary angioplasty in renal dialysis patients. Ann Thorac Surg 1996;61(6):1793-6.  Back to cited text no. 15
16.Rottembourg J, Mussat T, Gandjbakhch I. Open heart surgery in patients with end-stage renal disease. Proc Eur Dial Transplant Assoc 1983;20:169-75.  Back to cited text no. 16
17.Zipfel B, Welz A, Hildebrandt A, Hillebrandt G. Heart operations in dialysis patients. Aorto­coronary bypass operations and heart valve surgery-chronic dialysis patients. Fortschr Med 1988;106(35):699-703.  Back to cited text no. 17
18.Schmidt R, Weidemann H, Weihermu¨ller K, Bu¨cherl ES. Heart surgery in terminal kidney failure and dialysis dependent patients. Intra­operative hemofiltration for the prevention of hyperhydration. Zentralbl Chir 1989;114(5): 306-12.  Back to cited text no. 18
19.Grabensee B, Ivens K, Krian A. Extracardiac risk factors in heart surgery-the kidney. Z Kardiol 1990;79Suppl 4:47-57.  Back to cited text no. 19
20.Schmid C, Ziemer G, Laas J, Borst HG. Open­heart surgery in patients requiring chronic hemodialysis. Scand J Thorac Cardiovasc Surg 1992;26(2):97-100.  Back to cited text no. 20
21.Owen CH, Cummings RG, Sell TL, Schwab SJ, Jones RH, Glower DD. Coronary artery bypass grafting in patients with dialysis-depen­dent renal failure. Ann Thorac Surg 1994;58 (6):1729-33.  Back to cited text no. 21
22.Blum U, Skupin M, Wagner R, Matheis G, Oppermann F, Satter P. Early and long-term results of cardiac surgery in dialysis patients. Cardiovasc Surg 1994;2(1):97-100.  Back to cited text no. 22
23.Koyanagi T, Nishida H, Endo M, Koyanagi H. Coronary artery bypass grafting in chronic renal dialysis patients: Intensive perioperative dialysis and extensive usage of arterial grafts. Eur J Cardiothorac Surg 1994;8(9):505-7.  Back to cited text no. 23
24.Deleuze PH, Mazzucotelli JP, Maillet JM, et al. Cardiac surgery in chronic hemodialysed patients: Immediate and long-term results. Arch Mal Coeur Vaiss 1995;88(1):43-8.  Back to cited text no. 24
25.Garrido P, Bobadilla JF, Albertos J, et al. Car­diac surgery in patients under chronic hemo­dialysis. Eur J Cardiothorac Surg 1995;9(1): 36-9.  Back to cited text no. 25
26.Kobayashi J, Sasako Y, Kosakai Y. Results of coronary artery bypass grafting in dialysis patients. Nippon Kyobu Geka Gakkai Zasshi 1995;43:1625-30.  Back to cited text no. 26
27.Rinehart AL, Herzog CA, Collins AJ. A com­parison of coronary angioplasty and coronary artery bypass grafting outcomes in chronic dialysis patients. Am J Kidney Dis 1995;25(2): 281-90.  Back to cited text no. 27
28.Saigenji H, Nakamura N, Toyohira H, Shimo­kawa S, Moriyama Y, Taira A. Open heart sur­gery in patients with chronic dialysis. Nippon Kyobu Geka Gakkai Zasshi 1996;44(6):853-7.  Back to cited text no. 28
29.Samuels LE, Sharma S, Morris RJ, et al. Coronary artery bypass grafting in patients with chronic renal failure: A reappraisal. J Cardiac Surg 1996;11(2):128-33.  Back to cited text no. 29
30.Galli R, Nicolini F, Napoleone CP, et al. Heart surgery with cardiopulmonary bypass in pa­tients on chronic dialysis treatment: Our expe­rience. G Ital Cardiol 1996;26(9):1025-30.  Back to cited text no. 30

Correspondence Address:
Walid Trabelsi
Tunisian Military Hospital, 1008 Montfleury, Tunis
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PMID: 21060199

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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