Download Excellent Outcomes of Cardiac Surgery in Patients Infected with HIV

HIV/AIDS
BRIEF REPORT
Excellent Outcomes of Cardiac
Surgery in Patients Infected
with HIV in the Current Era
Farzan Filsoufi,1 Sacha P. Salzberg,1 Kai T. J. von Harbou,1
Eric Neibart,2 and David H. Adams1
Departments of 1Cardiothoracic Surgery and 2Infectious Diseases,
Mount Sinai Medical Center, New York, New York
Over the past decade, significant advances have been made
in the medical treatment of patients with human immunodeficiency virus type 1 infection, leading to a steady increase
in referrals for cardiac surgery. We report the outcome of
cardiac surgery recently performed in patients with documented human immunodeficiency virus type 1 infection.
Infection with HIV type 1 (HIV-1) has become a global public
heath problem. In 2003, 140 million people were estimated to
be infected with HIV. An estimated 850,000–950,000 people in
the United States are living with HIV infection, including
1200,000 who remain unaware of their infection [1]. Recent
decreases in the incidences of the disease have been reported
in western countries, particularly in the United States after the
introduction of HAART and protease inhibitors [1–3]. These
modern antiviral therapies have lead to a more-chronic evolution of this disease, with a significantly improved life expectancy and quality of life. Parallel to this improved survival, it
seems that there is a slight increase in the number of HIVinfected patients referred for cardiac surgery [4–7]. However,
the results of cardiac surgery among this patient population
remain largely unknown. The number of clinical studies is limited, with a wide range of reported operative mortalities [4–
7]. The paucity of reports in the literature makes it difficult to
draw any definite conclusions regarding the surgical management of such patients. We report our experience with this patient population, with an emphasis on operative outcomes and
midterm survival.
Patients and methods. We conducted a retrospective study
of 4952 patients who underwent cardiac surgery at Mount Sinai
Received 19 January 2006; accepted 22 April 2006; electronically published 11 July 2006.
Reprints or correspondence: Prof. Farzan Filsoufi, Dept. of Cardiothoracic Surgery, Mount
Sinai Medical Center, 1190 5th Ave., Box 1028, New York, NY 10029 (Farzan.filsoufi
@mountsinai.org).
Clinical Infectious Diseases 2006; 43:532–6
2006 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2006/4304-0022$15.00
532 • CID 2006:43 (15 August) • HIV/AIDS
Medical Center (New York, NY) from January 1998 through
December 2004. A thorough medical chart review was conducted to precisely identify cases of HIV infection among this
cohort. A total of 25 patients with serological test results positive for HIV were identified.
Additional preoperative, intraoperative, and postoperative
variables were collected using the cardiac surgery database and
by medical chart review. Follow-up information was obtained
by cross-matching each patient’s social security number with
the internet-based social security death index Web site (http:
//www.ancestory.com) [8]. If no death was recorded, the patient
was considered to be alive at the time of follow-up. This research was approved by our local institutional review board. A
waiver of signed and informed consent was obtained from each
patient. Every effort was made to safeguard the confidentiality
of personal health information. We used the revised Centers
for Disease Control and Prevention (CDC) classification system
for HIV-infected adolescents and adults [9].
Results. Characteristics of the 25 patients with HIV infection are summarized in table 1. The mode of infection was
sexual contact with HIV-infected partners in 8 patients (32%)
and injection drug abuse with possible shared or contaminated
supplies in 17 patients (68%). Decreased CD4+ cell count (!500
cells/mm3) was present in 17 patients (68%). With respect to
serological findings regarding CD4+ T lymphocyte count, 10
patients (40%) had counts determined to be in category one,
11 patients (44%) had counts determined to be in category 2,
and 4 patients (16%) had counts determined to be in category
3. Using the CDC’s classification, 16, 3, and 6 patients were
found to be in clinical class A, B, and C, respectively [10]. Nine
patients (36%) had a history of previous opportunistic infections. Thirteen patients (52%) were being actively treated with
antiretroviral therapy at the time of surgery, whereas 12 patients
(48%) were not receiving any HIV-specific medication immediately prior to surgery. All HIV-relevant data are shown in
table 1. Congestive heart failure was present in 7 patients (28%).
Previous stroke occurred in 4 patients (16%). Renal failure
(defined as a serum creatinine level 12.5 mg/dL) was present
in 2 patients (8%), whereas renal failure requiring dialysis was
noted in 2 patients (8%). Finally, liver cirrhosis (child B) after
viral hepatitis (B and C) was present in 2 patients (8%). Cardiac
surgery had been performed once previously in 4 patients
(16%). Surgery was performed on an elective, urgent, and
emergent basis in 11 patients (44%), 12 patients (48%), and 2
patients (8%), respectively. Median predicted operative mortality by EuroScore was 6% (r p 1.3–38.3).
Table 1. Demographic characteristics, preoperative risk factors, and outcomes.
Age in
years, sex
Coinfection
Clinical
category
CD4+ count,
cells/mm3
Drug regimen
Operative
mortality/morbidities
Status at follow-up
1
38, M
…
A
368
…
…
Alive at 78 months
2
48, M
…
A
256
…
…
Alive at 27 months
3
53, M
HBV
A
518
HAART, protease inhibitor, nNRTIs
…
Dead at 28 months
Patient
4
46, M
HBV and HCV
A
359
5
67, M
…
A
658
…
…
Alive at 17 months
…
Alive at 21 months
6
48, M
…
A
425
7
43, M
…
B
310
…
…
Alive at 56 months
…
…
8
60, M
…
B
51
Alive at 50 months
…
9
39, M
…
C
620
Alive at 42 months
…
10
45, M
…
A
325
HAART, nNRTIs
…
Alive at 41 months
Alive at 26 months
11
63, M
…
A
437
HAART, protease inhibitor, nNRTIs
…
Alive at 20 months
HAART, NRTIs
HAART, nNRTIs
…
12
57, M
…
A
450
…
…
Alive at 61 months
13
44, M
HCV
A
275
…
…
Alive at 47 months
14
33, M
…
A
415
…
…
Alive at 60 months
15
36, F
…
C
510
…
…
Alive at 72 months
16
38, F
…
C
893
HAART, nNRTIs
…
Alive at 59 months
17
31, M
…
A
538
HAART, protease inhibitor, nNRTIs
…
Alive at 72 months
18
50, M
…
A
188
…
…
Alive at 66 months
19
47, M
…
C
500
…
…
Alive at 90 months
…
Dead at 7 months
20
54, F
…
A
406
…
21
50, F
HBV and HCV
A
125
…
22
46, M
…
C
119
HAART, protease inhibitor, nNRTIs
23
34, F
HBV and HCV
A
406
24
46, M
HCV
B
802
25
62, M
HCV
a
C
1050
a
HAART, nNRTIs
Multiorgan system failure
…
Acute renal failure, respiratory
failure
Dead at 2 months
…
Respiratory failure
Alive at 81 months
…
Postoperative reoperation for
bleeding, sepsis
Alive at 11 months
Postoperative reoperation for
bleeding, sepsis
Alive at 10 months
NOTE. HBV, hepatitis B virus; HCV, hepatitis C virus; nNRTI, nonnucleoside reverse-transcriptase inhibitor; NRTI, nucleoside reverse-transcriptase inhibitor.
a
Patients with preoperative liver failure and/or cirrhosis.
The most common indication for surgery was endocarditis
(14 [56%] of 25 patients). Infective endocarditis involved the
aortic, mitral, and tricuspid valve in 6 patients (43%), 2 patients
(14%), and 1 patient (7%), respectively. Multivalve endocarditis
occurred in 5 patients (36%). Active endocarditis was present
in 29% of patients with valvular heart disease. In 7 patients
(28%), indication for surgery was severe coronary artery disease
(6 coronary artery bypass grafting, and 1 left ventricular aneurysm resection). Isolated aortic surgery was performed in 3
patients (12%; 2 instances of ascending aortic aneurysm repair
and 1 instance of isolated arch aneurysm repair). Finally, 1
young patient underwent a reoperation for aortic insufficiency
after a failed pulmonary autograft (Ross procedure). Table 2
depicts the detailed operative procedures. Mean SD cardiopulmonary bypass and cross-clamp times were 152 65 min
and 100 45 min, respectively.
In-hospital mortality was 4% (1 patient). The cause of death
was multiorgan system failure in a patient with fulminant endocarditis undergoing emergent valve surgery. Overall, 9 complications occurred in 5 patients, including the following: prolonged ventilation (124 h) caused by respiratory failure (2
cases), renal failure requiring temporary dialysis (1 case), sepsis
(2 cases), and reoperation for bleeding (2 cases). Table 1 shows
postoperative outcomes. No postoperative complications occurred in 20 patients (80%). It is noteworthy that no opportunistic infections appeared postoperatively during the hospital
stay. In 13 patients (52%), the hospital stay was !8 days; only
5 patients (20%) remained hospitalized for 110 days. Twentyone patients (84%) were discharged from the hospital to their
homes after surgery, whereas 3 patients (12%) were discharged
from the hospital to a subacute care facility for continued care.
Follow-up was considered to be 100% complete, and after a
median follow-up of 3.9 years (range, 1–7.5 years), late mortality
was 12.5% (3 of 24 patients). When this population was matched
to a similar group of patients undergoing cardiac surgery at our
institution during the same time period, no significant differences
were found. In the HIV group, actuarial survival was 92% and
86% at 1 and 3 years, respectively (figure 1).
Discussion. This is a descriptive report of a single-center
experience with open-heart surgery in 25 consecutive HIVinfected patients. We report a low operative mortality (4%) and
excellent early outcomes. Postoperative complications occurred
HIV/AIDS • CID 2006:43 (15 August) • 533
only in 5 patients (20%) (table 1), whereas no complications
occurred in the isolated coronary artery bypass grafting group.
Two of 3 late deaths occurred in patients with preoperative
CD4+ class 2 or 3. Clinical series reporting outcomes after
cardiac surgery in HIV-infected patients are rare. Table 3 summarizes clinical studies that include 120 HIV-infected patients
who underwent cardiac surgery. The improvement in operative
mortality observed in the most-recent series is probably related
to multiple factors, such as the following: important medical
advances in the treatment of HIV infection and AIDS, with the
introduction of highly active multidrug regimens, and advances
in perioperative care achieved over the past decade. In addition,
the decreased number of patients with infective endocarditis
and the concomitant increase in the number of patients with
coronary artery disease requiring surgical revascularization have
probably contributed to improved outcomes. Despite the decrease in operative mortality, postoperative morbidities persist
as a major issue among this population. In our case series,
postoperative complications occurred in 5 patients (20%).
These complications only occurred in patients with important
preoperative risk factors, such as previous opportunistic lung
infection (3 cases), clinical class C (2 cases), CD4+ class 3 (2
Figure 1. Survival comparison between HIV-infected patients and age
and sex matched, non–HIV-infected patients who underwent cardiac surgery at Mount Sinai Medical Center during 1998–2004.
cases), coinfection with hepatitis C virus (4 cases), advanced
liver cirrhosis (2 cases), and renal failure (3 cases) (table 1).
No complications occurred in the 6 patients (24%) who underwent isolated coronary artery bypass grafting. Infective en-
Table 2. Operative procedures and indications.
Patient
Indication
Coronary artery disease
VHD
Aorta
1
2
Ascending aortic aneurysm
CAD
…
CABG
…
…
Root
…
3
4
CAD
CAD
CABG
Off-pump CABG
…
…
…
…
5
6
CAD
CAD
Off-pump CABG
CABG
…
…
…
…
7
8
9
10
CAD
Endocarditis, CAD
Endocarditis
Aortic aneurysm
CABG
CABG
…
…
…
…
Arch
11
Endocarditis
…
AVR
…
12
Endocarditis
…
MVR
…
13
14
Endocarditis
Reoperative Ross
…
…
AVR and TVR
AVR
…
…
Urgent
…
15
16
Endocarditis
Endocarditis
…
…
AVR and TVR
AVR and TVR
…
Root
Urgent
Urgent
17
CAD
…
…
…
18
Endocarditis
…
AVR
…
Emergent
19
20
Endocarditis
Ascending aortic aneurysm
…
…
AVR
…
Root
Root
21
22
Endocarditis
Endocarditis
…
…
TVR
AVR and TVR
…
…
Emergent
Urgent
23
24
Endocarditis
Endocarditis
…
…
MVR
AVR
…
…
Urgent
Urgent
25
Endocarditis, CAD
AVR and TVR
…
Urgent
…
…
AVR
AVR
…
Left ventricular aneurysm
CABG
Priority
…
Urgent
…
…
Urgent
Urgent
…
…
…
…
Urgent
…
…
Urgent
NOTE. AVR, aortic valve replacement; CABG, coronary artery bypass grafting; CAD, coronary artery disease; MVR,
mitral valve repair; TVR, tricuspid valve repair.
534 • CID 2006:43 (15 August) • HIV/AIDS
Table 3. Clinical case series of 120 HIV-infected patients who underwent cardiac surgery.
Author, time period (no. of patients)
Aris et al. [6], 1986–1992 (n p 40)
Mestres et al. [7], 1985–2002 (n p 31)
a
Chong et al. [5], 1990–1999 (n p 22)
Trachiotis et al. [4], 1994–2000 (n p 37)
Present study, 1998–2004 (n p 25)
Patients who
underwent a
procedure for
VHD, %
Patients who
underwent a
procedure for
CAD, %
95
84
5
16
100
27
…
73
56
28
Operative
mortality, %
Morbidity, %
Survival at
1 year, %
NA
19
79
65
0
2.7
14
38
85
80
4
20
92
20
23
NOTE. CAD, coronary artery disease; CHF, congestive heart failure; NA, not available; VHD, valvular heart disease.
a
This study only reports outcomes of surgery in patients with valvular heart disease.
docarditis was the most common, if not the only indication
for cardiac surgery in HIV-infected patients in the 1980s [11–
13]. However, recent clinical case series have reported that an
increasing number of patients are referred for significant coronary artery disease requiring revascularization [14]. As the life
expectancy of these patients is increasing, they are more-exposed to the classical atherosclerotic risk factors [4, 5]. In addition, there is also evidence that new multidrug combinations
contribute to the development of premature coronary artery
disease [14–16]. These new drug regimens are also associated
with the development of a metabolic syndrome, including the
following: hypercholesterolemia, lipodystrophia, and insulin resistance. In our series, hypercholesterolemia was present in of
6 patients who underwent coronary artery bypass grafting. Similarly, Trachiotis et al. [4] reported an elevated cholesterol level
in patients who underwent coronary artery bypass grafting (19
of 23 patients experienced significant increases in their serum
cholesterol levels). The detrimental effects of chronic inflammation on coronary circulation have recently been documented
[17]. It appears that this also contributes and entertains coronary artery disease. Furthermore, the viral infection itself
might cause injury to the coronary endothelium and might
subsequently exacerbate atherosclerotic complications [16].
These data seem to suggest that HIV-infected patients treated
with modern drug regimens require close cardiologic monitoring, especially in the presence of any anginal equivalent.
Summary. In the early years of the HIV epidemic, the high
mortality related to this disease was a major concern, with
respect to any potential benefit that might be achieved after
cardiac surgery. The introduction of modern drug regimens for
the treatment of HIV infection and AIDS has led to a significant
increase in the life expectancy of these patients and a steady
increase in referrals for cardiac surgery. Currently, cardiac surgery can be performed safely on patients with AIDS or HIV
infection only with seemingly excellent early results. In addition, this study has shown that the 3-year survival is 180%
among this patient population. These findings have reinforced
our belief that surgeons should not hesitate to perform major
surgical procedures in patients with AIDS or HIV infection
only, whenever they are indicated.
Acknowledgments
Financial support. Department of Cardiothoracic Surgery, Mount
Sinai Medical Center.
Potential conflicts of interest. All authors: no conflicts.
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