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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. References 1. 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