Cardiac Surgery in Patients Undergoing Renal Dialysis or Transplantation John J. Lamberti, Jr., M.D., Lawrence H. Cohn, M.D., and John J. Collins, Jr., M.D. ABSTRACT The coexistence of organic cardiac disease and chronic renal failure presents a therapeutic dilemma. Cardiac operations have been performed on patients who were undergoing hemodialysis or who had had successful renal transplantation. There are several aspects of management of these patients which differ from those of the routine cardiac surgical patient. Guidelines for management are outlined and discussed.
T
he number of patients in chronic renal failure treated by dialysis or renal transplantation increases each year. Organic heart disease may coexist with chronic renal failure, often presenting a complex therapeutic problem. It has become necessary to evolve techniques for the management of organic heart disease in such patients. More than 50% of the deaths occurring in patients maintained on long-term hemodialysis are due to cardiovascular complications [7]. Hypertriglyceridemia is common in patients undergoing hemodialysis and is not improved by prolonged dialysis, nor is it cured by successful transplantation [l, 71. Hypertension and lipid abnormalities present in uremia may aggravate existing coronary artery disease, and coronary artery bypass graft procedures may be necessary for symptomatic relief [9]. Cardiac failure can result from simple fluid overload, uremic pericarditis with effusion and tamponade, bacterial endocarditis, or organic heart disease unrelated to uremia. T h e fluid and electrolyte imbalance present in uremia may hamper the management of cardiac failure in these patients. Adequate hemodialysis does not protect entirely against the occurrence of uremic pericarditis, as was once believed [16, 171, and the potential contamination through dialysis may predispose to bacterial From the Department of Surgery, Harvard Medical School, and the Division of Thoracic and Cardiac Surgery, Peter Bent Brigham Hospital, Boston, Mass. The authors wish to express their gratitude to John P. Merrill, M.D., Chief of the Renal Division a t the Peter Bent Brigham Hospital, for his assistance in the preparation of this manuscript and in coordinating the overall care and management of these patients. In addition, we would like to thank the other members of the dialysis and transplant groups for their aid in managing these chronically ill patients. Accepted for publication Sept. 18, 1974. Address reprint requests to Dr. Collins, Peter Bent Brigham Hospital, 721 Huntington Ave., Boston, Mass. 02115.
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endocarditis [ 141. Cardiac operations have been successfully performed in patients on hemodialysis or who have had renal transplantation [5, 8, 91. T h e following 4 patients with renal problems who required cardiopulmonary bypass for correction of organic heart disease are reviewed because basic principles of management are well illustrated.
Case Histories PATIENT 1
A 3 1-year-oldwoman was first seen with a one-year history of progressive renal failure, hypertension, and congestive heart failure. Physical examination revealed an enlarged heart and murmurs of aortic insufficiency. T h e renal disease was chronic glomerulonephritis with the nephrotic syndrome. Initial management with peritoneal dialysis yielded a negative fluid balance of 18 liters. Despite an intensive treatment program, congestive failure remained a severe problem. Blood cultures were negative. Hyperkalemia was particularly difficult to control in spite of the use of Kayexalate" exchange resins. Cardiac catheterization revealed 3+ aortic regurgitation with a left ventricular end-diastolic pressure (LVEDP) of 20 mm Hg at rest and 26 mm Hg with exercise. In June, 1971, aortic valve replacement was performed with a No. 9 Starr-Edwards ( 1260 series) aortic valve prosthesis. Pathological examination of the excised valve showed no evidence of bacterial endocarditis; there was basophilic degeneration with fibrosis and vascularization. A specific diagnosis could not be established. Dialysis was performed the night prior to operation and again on the first postoperative day. Serum potassium was maintained between 4.0 and 5.0 mEq per liter by judicious use of potassium administered intravenously. T h e patient had a smooth postoperative course and was discharged on the twelfth postoperative day on a regimen of Coumadin. Three years after operation she is on long-term hemodialysis and is doing well. No cardiotonic drugs are required. PATIENT 2
A 43-year-old man had chronic renal failure secondary to polycystic kidney disease. He had been on hemodialysis for two years when a series of septic episodes occurred. These were thought to be due to residual infection in his kidneys, and bilateral nephrectomy was performed. Postoperatively, he developed a wound infection due to mixed flora, including Staphylococcus aureus. An infection of the shunt was treated with oxacillin. Nine months prior to his heart operation the symptoms of fever, diastolic murmur, and increased pulse pressure appeared. S. aureus was cultured from the blood, and intravenous oxacillin therapy for bacterial endocarditis was begun. Cardiac function remained satisfactory in spite of aortic insufficiency. In April, 1968, a renal allograft procedure using a cadaver kidney was *Winthrop Laboratories, New York, N.Y.
136
THE ANNALS OF THORACIC SURGERY
Cardiac Surgery in Dialysis or Transplantation performed without incident. He was discharged three weeks after transplantation with a serum creatinine of 1.7 mg per 100 ml. Despite excellent renal function, progressive cardiac failure occurred over the next four months. Aortic valve replacement was performed in September, 1968, using a large Harken Surgitool cloth-covered valve. He was discharged on the twelfth postoperative day on a regimen of Coumadin, prednisone, and Imuran. T h e serum creatinine is stable at 1.7 mg per 100 ml six years after renal transplantation and aortic valve replacement. Steroid management at the time of the heart operation consisted of 300 mg of hydrocortisone sodium succinate on the day of operation; by the seventh postoperative day this had been tapered down to the maintenance dose of prednisone. Since operation he has had no cardiac problems and is currently gainfully employed without anticoagulants or cardiac medication.
3 A 32-year-old man with renal failure due to chronic glomerulonephritis in a solitary kidney entered the dialysis program because of severe hypertension refractory to medical therapy. With dialysis his hypertension was controlled. Renal homotransplantation with a kidney from his father was performed in 1967. H e did well for four years with stable renal function when angina pectoris occurred. This progressed, and Demerol was often required for control of the pain. In October, 1971, his electrocardiogram showed instability, with ischemic changes in the lateral leads during an episode of chest pain. In November, 1971, cardiac catheterization revealed 95% obstruction of the left anterior descending coronary artery and minor changes in the circumflex coronary artery system. There was diffuse nonobstructive disease in the nondominant right coronary artery. Ventricular function was abnormal with a left ventricular end-diastolic pressure of 18 mm Hg which rose to 24 mm Hg after the ventriculogram was obtained. Lipoprotein electrophoresis findings and serum cholesterol were normal. On one occasion serum triglycerides were elevated. In December, 1971, a saphenous vein bypass graft procedure to the left anterior descending coronary artery was performed. Steroid coverage was provided with 300 mg of hydrocortisone sodium succinate on the day of operation; this was then tapered off over seven days to a maintenance dose of prednisone, 5 mg twice a day. After operation changes of an acute anterolateral myocardial infarction were seen, but no major complications occurred. He was discharged on the twenty-fourth postoperative day with excellent relief of his angina. Two months postoperatively cardiac catheterization revealed a patent vein graft to the distal left anterior descending coronary artery. He is currently doing well thirty months postoperatively.
PATIENT
4 A 44-year-old man was in renal failure secondary to chronic glomerulonephritis. Approximately one year after beginning hemodialysis he
PATIENT
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developed a persistent pericardial effusion refractory to dialysis therapy. Three pericardiocentesis procedures were performed during a six-week period after which he improved and was discharged. Three months later he was chronically ill with gross ascites, elevated neck veins, and a trace of peripheral edema. Blood pressure was 110/70 with a paradoxical pulse of 10 mm Hg. Cardiac catheterization revealed a right atrial mean pressure of 15 mm Hg; left ventricular pressure was 110/16 mm Hg. Pulmonary artery pressure was 30/ 15 mm Hg, and pulmonary capillary wedge pressure was 16 mm Hg. A Valsalva maneuver produced a square-wave response with both pulmonary capillary and right atrial pressure rising to 60 mm Hg and maintaining a similar configuration. Sternotomy in April, 1973, revealed a thickened constrictive pericardium, and cardiopulmonary bypass was utilized while a complete pericardiectomy was performed. After operation the venous pressure was low, averaging 1 to 3 cm H 2 0 with a systemic arteriovenous pressure of 100/70 mm Hg. He-underwent dialysis the night prior to operation and again on the first postoperative day. All transfusions were done with frozen washed packed red cells. In February, 1974, renal homotransplantation was performed. Current renal function is stable, and there are no cardiac symptoms.
Manage m e n t Our general approach in operating upon patients with chronic renal failure who are on dialysis has already been described [Z, 13, 161. Certain aspects of management differ from regimens reported from other centers [5, 81. Our patients undergo dialysis on the evening prior to operation, and the operation is usually performed less than twelve hours after completion of the dialysis. During this preoperative dialysis the hematocrit is elevated to about 30 vol per 100 ml by transfusion. Transfusion during dialysis allows management of the circulating blood volume in these patients and protects against volume overload. All transfusions are done with frozen blood or washed red cells in order to minimize antigen exposure for the patient who may be either a transplant recipient or a future candidate for transplantation [ll]. The first 3 patients received washed packed cells while the fourth was managed with frozen blood [3]. Serum potassium is determined two or three hours before operation, and hyperkalemia is treated with Kayexalate enemas if necessary [Z, 131. Cardiopulmonary bypass is instituted with complete hemodilution. T h e pump prime consists of 1,600 ml of Ringer’s lactate solution, 100 gm of saltpoor albumin, and 50 ml of 50% glucose. If tolerated, blood for an autologous transfusion may be removed prior to the beginning of cardiopulmonary bypass. This blood is returned at the completion of extracorporeal circulation. After operation the remaining blood in the pump
138
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Cardiac Surgery in Dialysis or Transplantation
is drained and centrifuged, and the red cells are returned to the patient. Frozen blood may be used in the pump prime and for postoperative transfusions [3]. T h e coagulation defects identified in chronic uremia have not been a problem in patients who are well dialyzed. I n general, routine hemodialysis using regional anticoagulation is performed on the first postoperative day. Management of volume replacement is guided by measurement of left and right atrial pressures. Electrolyte management is simplified in patients on dialysis since urinary potassium losses are not a factor. Free water, 800 to 1,000 ml, is administered to replace insensible losses [ll]. If fluid overload becomes a problem, daily ultrafiltration hemodialysis in combination with intravenous administration of salt-poor albumin can yield a large negative fluid balance. A recurrent problem in operations on patients on dialysis is clotting in the dialysis access route [6, 13, 151. Careful attention must be paid to the position of the extremity that contains the shunt. Compression must be avoided, and blood pressure is not measured in that arm. A slow infusion of heparin into both limbs of the Silastic shunt during the operation and in the postoperative period will aid in maintaining patency. Antibiotic prophylaxis is a mildly controversial area in open-heart surgery. Although the need for antibiotic therapy has not been definitely established, we recommend that these patients receive prophylactic antibiotic coverage dui-ing the preoperative and postoperative period. All our patients received Keflin" prior to, during, and for four days after operation. No complications due to infection were seen. Patients on long-term steroid therapy are known to have adrenal suppression. We treat all patients with adrenal insufficiency with 300 mg of hydrocortisone sodium succinate on the day of operation. This may be given intravenously in divided doses. Beginning on the first postoperative day, the dose is rapidly tapered to a maintenance level by the seventh postoperative day [12]. Tissue valves are now used for cardiac valve replacement. These valves should be considered for patients in whom long-term anticoagulation may be hazardous, such as transplant recipients on chronic steroid therapy. T h e glutaraldehyde-stabilized heterograft [ 181 would seem to be ideal for the patient who is a candidate for transplantation.
Comment These 4 patients demonstrate the variety of organic cardiac diseases that may be seen in the transplant and dialysis population. As in patients with normal renal function, there is a spectrum of severity. T h e clinical team must determine whether the cardiac lesion requires immediate or urgent operation or can be managed by judicious dialysis and medical care. *Eli Lilly and Co., Indianapolis, Ind.
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2, FEBRUARY,
1975
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LAMBERTI, COHN, AND COLLINS Patients 1 and 2 both suffered from severe aortic insufficiency. In Patient 1 dialysis could nor control congestive failure, and aortic valve replacement assumed the highest priority. In the second patient cardiac failure was not an early problem, and renal transplantation was performed. It is possible that steroid therapy aggravated the existing cardiac failure in this young man. Cardiac valve replacement may be lifesaving in patients who develop acute or chronic insufficiency of the mitral or aortic valve. T h e third patient represents a group that may be expected to increase in number in the future [7]. This man had coronary artery disease aggravated and possibly accelerated by long-term hypertension and then renal failure. Hypertriglyceridemia is common in patients undergoing dialysis [7]. It is not improved-and perhaps may even be aggravated-by prolonged dialysis. This hypertriglyceridemia may persist after transplanta; tion [l]. Successful hemodialysis or renal transplantation affords many patients an increased range of activities. As the cardiovascular disease progresses, these patients may become symptomatic even though they have relatively normal renal function. There is a small number of patients with angina pectoris in our dialysis group at the present time. Angina occurring during dialysis is managed by supplemental oxygen, analgesics, volume replacement, and vasopressors, if necessary, to maintain an adequate diastolic blood pressure. These patients may require higher maintenance hematocrit levels than other dialysis patients. In the future it is possible that more patients with angina will require coronary artery bypass graft procedures while on dialysis or after transplantation. T h e fourth patient represents a problem common to all dialysis programs. Initially he suffered from recurrent uremic pericardial effusions. T h e approach to such effusions varies from one center to another [4, 10, 16, 171. We prefer to perform multiple pericardiocenteses before resorting to the creation of a pericardial window. Most of these patients will not require operation. Rarely, a patient may develop late constrictive pericarditis, as did the patient reported here and 2 in our previous report [17]. I n this situation we prefer to utilize cardiopulmonary bypass when performing a total pericardiectomy for the constrictive pericarditis.
References 1. Cassaretto, A. A., Marchiuro, J. L., and Bagdade, 1. D. Hyperlipidemia following renal transplant. Trans Am Soc Artif Intern Organs 19:154, 1973. 2. Hampers, C. L., Bailey, G. L., Hager, E. B., Vandam, L. D., and ,Merrill, J. Pi Major surgery in patients on maintenance hemodialysis. Am J Surg 115:747, 1968. 3. Hanson, E. L., Fosberg, A. M., LaCava, E. J., Stetz, C. W., and Collins, J. J., Jr. Studies with frozen blood for oxygenator priming. J Thorac Cardimasc Surg 64:87, 1972. 4. Koopot, R., Zerefos, N., Lavender, A., and Pifarre, R. Cardiac tamponade in uremic pericarditis. A m J Cardiol32:846, 1973.
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THE ANNALS OF THORACIC SURGERY
Cardiac Surgery in Dialysis or Transplantation 5. Lansing, A. M., Leb, D. E., and Berman, L. B. Cardiovascular surgery in end stage renal failure. JAMA 204:682, 1968. 6 . Lawton, R. L., Gulesserian, H. P., and Rossi, N. P. Surgical problems in patients on maintenance hemodialysis. Arch Surg 97:283, 1968. 7. Lowrie, E. G., Lazarus, J. M., Hampers, C. L., and Merrill, J. P. Cardiovascular disease in dialysis patients (editorial). N Engl J Med 290:737, 1974. 8 . Manhas, D. R., and Merendino, K A. T h e management of cardiac surgery in patients with chronic renal failure. J Thorac Cardiouasc Surg 63:235, 1972. 9. Menzoian, J., Davis, R . C., Idelson, B. A., Mannick, J. A., and Berger, R. Coronary artery bypass surgery and renal transplantation: A case report. Ann Surg 179:63, 1974. 10. Merrill, J. P. Cardiovascular problems in patients on long-term hemodialysis (editorial). J A M A 228: 1149, 1974. 11. Merrill, J . P., and Hampers, C. L. Uremia. N Engl J Med 282: 1014, 1970. 12. Newsome, H. H., Jr., and Manalan, S. A. Plasma cortisol and cortisone concentrations following postoperative adrenal steroid replacement. Surgery 73:429, 1973. 13. Patil, J., Bennett, A. H., Bailey, C. L., Maloney, E. M., and Harrison, J. H. Simultaneous bilateral nephrectomy from a posterior approach. Surg Gynecol Obstet 134:764, 1972. 14. Ribot, S., Gilbert, L., Rothfeld, E. L., Parsonnet, V., and Jacobs, M. G. Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemodialysis-dependent patient. J Thorac Cardiovasc Surg 62:59, 1971. 15. Rosenberg, J. C. Dialysis as a substitute for renal function in the surgical patient. Curr Probl Surg, February 1972. 16. Singh, S., Newmark, K., Ishikawa, I., Mitra, S., and Berman, L. Pericardiectomy in uremia. JAMA 228: 1132, 1974. 17. Wolfe, S. A., Bailey, G. F., and Collins, J. J., Jr. Constrictive pericarditis after uremic effusion. J Thorac Cardiouasc Surg 63:540, 1972. 18. Zuhdi, N., Hawley, W., Voehl, V., Hancock, W., Carey, J., and Greer, A. Porcine aortic valves as replacements for human heart valves. Ann Thovac Surg 17:479, 1974.
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T
he number of patients in chronic renal failure treated by dialysis or renal transplantation increases each year. Organic heart disease may coexist with chronic renal failure, often presenting a complex therapeutic problem. It has become necessary to evolve techniques for the management of organic heart disease in such patients. More than 50% of the deaths occurring in patients maintained on long-term hemodialysis are due to cardiovascular complications [7]. Hypertriglyceridemia is common in patients undergoing hemodialysis and is not improved by prolonged dialysis, nor is it cured by successful transplantation [l, 71. Hypertension and lipid abnormalities present in uremia may aggravate existing coronary artery disease, and coronary artery bypass graft procedures may be necessary for symptomatic relief [9]. Cardiac failure can result from simple fluid overload, uremic pericarditis with effusion and tamponade, bacterial endocarditis, or organic heart disease unrelated to uremia. T h e fluid and electrolyte imbalance present in uremia may hamper the management of cardiac failure in these patients. Adequate hemodialysis does not protect entirely against the occurrence of uremic pericarditis, as was once believed [16, 171, and the potential contamination through dialysis may predispose to bacterial From the Department of Surgery, Harvard Medical School, and the Division of Thoracic and Cardiac Surgery, Peter Bent Brigham Hospital, Boston, Mass. The authors wish to express their gratitude to John P. Merrill, M.D., Chief of the Renal Division a t the Peter Bent Brigham Hospital, for his assistance in the preparation of this manuscript and in coordinating the overall care and management of these patients. In addition, we would like to thank the other members of the dialysis and transplant groups for their aid in managing these chronically ill patients. Accepted for publication Sept. 18, 1974. Address reprint requests to Dr. Collins, Peter Bent Brigham Hospital, 721 Huntington Ave., Boston, Mass. 02115.
VOL.
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NO. 2, FEBRUARY,
1975
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endocarditis [ 141. Cardiac operations have been successfully performed in patients on hemodialysis or who have had renal transplantation [5, 8, 91. T h e following 4 patients with renal problems who required cardiopulmonary bypass for correction of organic heart disease are reviewed because basic principles of management are well illustrated.
Case Histories PATIENT 1
A 3 1-year-oldwoman was first seen with a one-year history of progressive renal failure, hypertension, and congestive heart failure. Physical examination revealed an enlarged heart and murmurs of aortic insufficiency. T h e renal disease was chronic glomerulonephritis with the nephrotic syndrome. Initial management with peritoneal dialysis yielded a negative fluid balance of 18 liters. Despite an intensive treatment program, congestive failure remained a severe problem. Blood cultures were negative. Hyperkalemia was particularly difficult to control in spite of the use of Kayexalate" exchange resins. Cardiac catheterization revealed 3+ aortic regurgitation with a left ventricular end-diastolic pressure (LVEDP) of 20 mm Hg at rest and 26 mm Hg with exercise. In June, 1971, aortic valve replacement was performed with a No. 9 Starr-Edwards ( 1260 series) aortic valve prosthesis. Pathological examination of the excised valve showed no evidence of bacterial endocarditis; there was basophilic degeneration with fibrosis and vascularization. A specific diagnosis could not be established. Dialysis was performed the night prior to operation and again on the first postoperative day. Serum potassium was maintained between 4.0 and 5.0 mEq per liter by judicious use of potassium administered intravenously. T h e patient had a smooth postoperative course and was discharged on the twelfth postoperative day on a regimen of Coumadin. Three years after operation she is on long-term hemodialysis and is doing well. No cardiotonic drugs are required. PATIENT 2
A 43-year-old man had chronic renal failure secondary to polycystic kidney disease. He had been on hemodialysis for two years when a series of septic episodes occurred. These were thought to be due to residual infection in his kidneys, and bilateral nephrectomy was performed. Postoperatively, he developed a wound infection due to mixed flora, including Staphylococcus aureus. An infection of the shunt was treated with oxacillin. Nine months prior to his heart operation the symptoms of fever, diastolic murmur, and increased pulse pressure appeared. S. aureus was cultured from the blood, and intravenous oxacillin therapy for bacterial endocarditis was begun. Cardiac function remained satisfactory in spite of aortic insufficiency. In April, 1968, a renal allograft procedure using a cadaver kidney was *Winthrop Laboratories, New York, N.Y.
136
THE ANNALS OF THORACIC SURGERY
Cardiac Surgery in Dialysis or Transplantation performed without incident. He was discharged three weeks after transplantation with a serum creatinine of 1.7 mg per 100 ml. Despite excellent renal function, progressive cardiac failure occurred over the next four months. Aortic valve replacement was performed in September, 1968, using a large Harken Surgitool cloth-covered valve. He was discharged on the twelfth postoperative day on a regimen of Coumadin, prednisone, and Imuran. T h e serum creatinine is stable at 1.7 mg per 100 ml six years after renal transplantation and aortic valve replacement. Steroid management at the time of the heart operation consisted of 300 mg of hydrocortisone sodium succinate on the day of operation; by the seventh postoperative day this had been tapered down to the maintenance dose of prednisone. Since operation he has had no cardiac problems and is currently gainfully employed without anticoagulants or cardiac medication.
3 A 32-year-old man with renal failure due to chronic glomerulonephritis in a solitary kidney entered the dialysis program because of severe hypertension refractory to medical therapy. With dialysis his hypertension was controlled. Renal homotransplantation with a kidney from his father was performed in 1967. H e did well for four years with stable renal function when angina pectoris occurred. This progressed, and Demerol was often required for control of the pain. In October, 1971, his electrocardiogram showed instability, with ischemic changes in the lateral leads during an episode of chest pain. In November, 1971, cardiac catheterization revealed 95% obstruction of the left anterior descending coronary artery and minor changes in the circumflex coronary artery system. There was diffuse nonobstructive disease in the nondominant right coronary artery. Ventricular function was abnormal with a left ventricular end-diastolic pressure of 18 mm Hg which rose to 24 mm Hg after the ventriculogram was obtained. Lipoprotein electrophoresis findings and serum cholesterol were normal. On one occasion serum triglycerides were elevated. In December, 1971, a saphenous vein bypass graft procedure to the left anterior descending coronary artery was performed. Steroid coverage was provided with 300 mg of hydrocortisone sodium succinate on the day of operation; this was then tapered off over seven days to a maintenance dose of prednisone, 5 mg twice a day. After operation changes of an acute anterolateral myocardial infarction were seen, but no major complications occurred. He was discharged on the twenty-fourth postoperative day with excellent relief of his angina. Two months postoperatively cardiac catheterization revealed a patent vein graft to the distal left anterior descending coronary artery. He is currently doing well thirty months postoperatively.
PATIENT
4 A 44-year-old man was in renal failure secondary to chronic glomerulonephritis. Approximately one year after beginning hemodialysis he
PATIENT
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developed a persistent pericardial effusion refractory to dialysis therapy. Three pericardiocentesis procedures were performed during a six-week period after which he improved and was discharged. Three months later he was chronically ill with gross ascites, elevated neck veins, and a trace of peripheral edema. Blood pressure was 110/70 with a paradoxical pulse of 10 mm Hg. Cardiac catheterization revealed a right atrial mean pressure of 15 mm Hg; left ventricular pressure was 110/16 mm Hg. Pulmonary artery pressure was 30/ 15 mm Hg, and pulmonary capillary wedge pressure was 16 mm Hg. A Valsalva maneuver produced a square-wave response with both pulmonary capillary and right atrial pressure rising to 60 mm Hg and maintaining a similar configuration. Sternotomy in April, 1973, revealed a thickened constrictive pericardium, and cardiopulmonary bypass was utilized while a complete pericardiectomy was performed. After operation the venous pressure was low, averaging 1 to 3 cm H 2 0 with a systemic arteriovenous pressure of 100/70 mm Hg. He-underwent dialysis the night prior to operation and again on the first postoperative day. All transfusions were done with frozen washed packed red cells. In February, 1974, renal homotransplantation was performed. Current renal function is stable, and there are no cardiac symptoms.
Manage m e n t Our general approach in operating upon patients with chronic renal failure who are on dialysis has already been described [Z, 13, 161. Certain aspects of management differ from regimens reported from other centers [5, 81. Our patients undergo dialysis on the evening prior to operation, and the operation is usually performed less than twelve hours after completion of the dialysis. During this preoperative dialysis the hematocrit is elevated to about 30 vol per 100 ml by transfusion. Transfusion during dialysis allows management of the circulating blood volume in these patients and protects against volume overload. All transfusions are done with frozen blood or washed red cells in order to minimize antigen exposure for the patient who may be either a transplant recipient or a future candidate for transplantation [ll]. The first 3 patients received washed packed cells while the fourth was managed with frozen blood [3]. Serum potassium is determined two or three hours before operation, and hyperkalemia is treated with Kayexalate enemas if necessary [Z, 131. Cardiopulmonary bypass is instituted with complete hemodilution. T h e pump prime consists of 1,600 ml of Ringer’s lactate solution, 100 gm of saltpoor albumin, and 50 ml of 50% glucose. If tolerated, blood for an autologous transfusion may be removed prior to the beginning of cardiopulmonary bypass. This blood is returned at the completion of extracorporeal circulation. After operation the remaining blood in the pump
138
THE ANNALS OF THORACIC SURGERY
Cardiac Surgery in Dialysis or Transplantation
is drained and centrifuged, and the red cells are returned to the patient. Frozen blood may be used in the pump prime and for postoperative transfusions [3]. T h e coagulation defects identified in chronic uremia have not been a problem in patients who are well dialyzed. I n general, routine hemodialysis using regional anticoagulation is performed on the first postoperative day. Management of volume replacement is guided by measurement of left and right atrial pressures. Electrolyte management is simplified in patients on dialysis since urinary potassium losses are not a factor. Free water, 800 to 1,000 ml, is administered to replace insensible losses [ll]. If fluid overload becomes a problem, daily ultrafiltration hemodialysis in combination with intravenous administration of salt-poor albumin can yield a large negative fluid balance. A recurrent problem in operations on patients on dialysis is clotting in the dialysis access route [6, 13, 151. Careful attention must be paid to the position of the extremity that contains the shunt. Compression must be avoided, and blood pressure is not measured in that arm. A slow infusion of heparin into both limbs of the Silastic shunt during the operation and in the postoperative period will aid in maintaining patency. Antibiotic prophylaxis is a mildly controversial area in open-heart surgery. Although the need for antibiotic therapy has not been definitely established, we recommend that these patients receive prophylactic antibiotic coverage dui-ing the preoperative and postoperative period. All our patients received Keflin" prior to, during, and for four days after operation. No complications due to infection were seen. Patients on long-term steroid therapy are known to have adrenal suppression. We treat all patients with adrenal insufficiency with 300 mg of hydrocortisone sodium succinate on the day of operation. This may be given intravenously in divided doses. Beginning on the first postoperative day, the dose is rapidly tapered to a maintenance level by the seventh postoperative day [12]. Tissue valves are now used for cardiac valve replacement. These valves should be considered for patients in whom long-term anticoagulation may be hazardous, such as transplant recipients on chronic steroid therapy. T h e glutaraldehyde-stabilized heterograft [ 181 would seem to be ideal for the patient who is a candidate for transplantation.
Comment These 4 patients demonstrate the variety of organic cardiac diseases that may be seen in the transplant and dialysis population. As in patients with normal renal function, there is a spectrum of severity. T h e clinical team must determine whether the cardiac lesion requires immediate or urgent operation or can be managed by judicious dialysis and medical care. *Eli Lilly and Co., Indianapolis, Ind.
VOL.
19, NO.
2, FEBRUARY,
1975
139
LAMBERTI, COHN, AND COLLINS Patients 1 and 2 both suffered from severe aortic insufficiency. In Patient 1 dialysis could nor control congestive failure, and aortic valve replacement assumed the highest priority. In the second patient cardiac failure was not an early problem, and renal transplantation was performed. It is possible that steroid therapy aggravated the existing cardiac failure in this young man. Cardiac valve replacement may be lifesaving in patients who develop acute or chronic insufficiency of the mitral or aortic valve. T h e third patient represents a group that may be expected to increase in number in the future [7]. This man had coronary artery disease aggravated and possibly accelerated by long-term hypertension and then renal failure. Hypertriglyceridemia is common in patients undergoing dialysis [7]. It is not improved-and perhaps may even be aggravated-by prolonged dialysis. This hypertriglyceridemia may persist after transplanta; tion [l]. Successful hemodialysis or renal transplantation affords many patients an increased range of activities. As the cardiovascular disease progresses, these patients may become symptomatic even though they have relatively normal renal function. There is a small number of patients with angina pectoris in our dialysis group at the present time. Angina occurring during dialysis is managed by supplemental oxygen, analgesics, volume replacement, and vasopressors, if necessary, to maintain an adequate diastolic blood pressure. These patients may require higher maintenance hematocrit levels than other dialysis patients. In the future it is possible that more patients with angina will require coronary artery bypass graft procedures while on dialysis or after transplantation. T h e fourth patient represents a problem common to all dialysis programs. Initially he suffered from recurrent uremic pericardial effusions. T h e approach to such effusions varies from one center to another [4, 10, 16, 171. We prefer to perform multiple pericardiocenteses before resorting to the creation of a pericardial window. Most of these patients will not require operation. Rarely, a patient may develop late constrictive pericarditis, as did the patient reported here and 2 in our previous report [17]. I n this situation we prefer to utilize cardiopulmonary bypass when performing a total pericardiectomy for the constrictive pericarditis.
References 1. Cassaretto, A. A., Marchiuro, J. L., and Bagdade, 1. D. Hyperlipidemia following renal transplant. Trans Am Soc Artif Intern Organs 19:154, 1973. 2. Hampers, C. L., Bailey, G. L., Hager, E. B., Vandam, L. D., and ,Merrill, J. Pi Major surgery in patients on maintenance hemodialysis. Am J Surg 115:747, 1968. 3. Hanson, E. L., Fosberg, A. M., LaCava, E. J., Stetz, C. W., and Collins, J. J., Jr. Studies with frozen blood for oxygenator priming. J Thorac Cardimasc Surg 64:87, 1972. 4. Koopot, R., Zerefos, N., Lavender, A., and Pifarre, R. Cardiac tamponade in uremic pericarditis. A m J Cardiol32:846, 1973.
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