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Ann Thorac Surg 1997;63:143-146
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Open Heart Operations After Renal Transplantation

Departments of Thoracic and Cardiovascular Surgery, Nephrology, and Abdominal and Transplant Surgery, Hannover Medical School, Hannover, Germany

Accepted for publication July 23, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Because of the increasing number of renal transplantations performed, secondary cardiac operations in these patients are discussed concerning their impact on patient and graft survival.

Methods. We reviewed our experience in 45 patients (33 male and 12 female) who underwent open heart operations after previous renal transplantation. Thirty-one patients (group I) received coronary artery bypass grafting and 14 (group II) underwent valve replacement. Mean age at the time of operation was 55 ± 9 years. The interval between renal transplantation and cardiac operation was 57 ± 39 months (range, 5 days to 174 months). All patients had functioning renal allografts with preoperative serum creatinine levels ranging from 100 to 338 mol/mL (mean ± standard deviation, 195 ± 86).

Results. Overall early operative mortality (30 days) was 8.8% (group I, 1 patient; group II, 3 patients). Underlying causes of death were septic endocarditis (n = 2, group II), necrotizing enterocolitis (n = 1, group I), and myocardial infarction (n = 1, group II). One further patient in group II also died of septic endocarditis after 69 days (in-hospital death). The mean follow-up of the 40 surviving patients was 44 ± 31 months. There was another late death (24 months postoperatively) caused by coagulopathy. Four patients had returned to hemodialysis at intervals of 27 to 83 months (mean, 51 months) because of renal transplant failure. In all patients, the function of the renal allograft was not impaired by open heart operation.

Conclusions. Open heart operations in renal transplant recipients have acceptable mortality and morbidity rates. In almost all patients, function of the transplanted organ can be maintained at the preoperative level.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Renal transplantation, coronary artery bypass grafting (CABG), and heart valve replacement are well-established procedures. In patients with end-stage renal disease, atherosclerotic heart disease remains the leading cause of death. Because several studies [1–10] reported symptomatic improvement and low operative mortality after open heart operations in selected groups of patients with end-stage renal disease, we investigated the impact of open heart operations on morbidity and mortality in renal transplant recipients as well as on renal graft function.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The records of the cardiovascular surgery department and the renal transplantation service at the University Hospital of Hannover from 1970 to 1994 were reviewed. Forty-five patients (33 male, 12 female) were identified who had undergone an open heart operation after renal transplantation.

Charts were reviewed for factors relating to the patients' end-stage renal disease, including cause, date of initiation of dialysis, date of renal transplantation, and immunosuppression therapy. Perioperative data included indication for operation, type of procedure, date of procedure, postoperative course, and complications. In addition, preoperative New York Heart Association functional classification and cardiac catheterization data were reviewed, and the severity of coronary artery disease or heart valve disease was assessed.

The mean age of the patients at cardiac operation was 55 ± 9 years, and the interval between renal transplantation and OHO was 57 ± 39 months. Before renal transplantation, the patients had dialysis treatment for 58 ± 46 months. The causes of end-stage renal disease are summarized in Table 1. Three of 45 patients had received a second renal graft. Immunosuppression therapy included cyclosporin A, prednisolone, and azathioprine. Single-drug therapy was used in 1 of the 45 patients and triple therapy in 5; the rest (39/45) had a double immunosuppression protocol. Preoperative serum creatinine levels ranged from 100 to 338 mol/L (mean, 186 ± 81 mol/L), and blood urea nitrogen levels ranged from 5.6 to 28.2 mmol/L (mean, 14.7 ± 6.2 mmol/L). There was no significant difference between groups I and II.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Forty of 45 patients survived the operation (group I, 30/31; group II, 10/14). Operative mortality (30 days) was 8.8% (group I, 1 patient; group II, 3 patients). In group I, 1 patient died of sepsis on the 12th postoperative day after emergency coronary artery bypass grafting (CABG) and resection of a ventricular aneurysm. In group II, 1 patient died on the third postoperative day after emergency aortic valve replacement (AVR) for acute endocarditis and ventricular myotomy for hypertrophic cardiomyopathy due to sepsis. Another patient died of myocardial infarction 5 days postoperatively after AVR. The third patient had received AVR and mitral valve replacement (MVR) for acute endocarditis and died 30 days postoperatively of necrotizing entercolitis. One patient who had received emergency MVR for mitral valve endocarditis died of sepsis 69 days postoperatively. There was only one late death after 24 months, due to coagulopathy in a patient who had received MVR for mitral valve endocarditis. Two patients with a prolonged postoperative course after CABG became anuric and required hemodialysis. In 1, the renal graft function recovered and hemodialysis was stopped. The other patient became septic, and because ultrasound, computed tomography, and leukoscan showed strong evidence that the transplanted kidney was the source of septicemia, the allograft was explanted.

Thirty-one patients underwent CABG (group I), 13 patients had isolated valve operations, and 1 had a combined valvular and coronary operation (group II). For coronary revascularization (group I), 10 patients received saphenous veins for all bypasses, and in 21 patients the left internal mammary artery also was used. A mean of 3.0 grafts were bypassed. In 1 patient, patching of a left ventricular aneurysm was done simultaneously, and another patient had carotid endarterectomy. The valve operations (group II) included AVR in 4 patients; AVR plus replacement of the ascending aorta in 2 patients; isolated MVR in 3 patients; combined AVR and MVR in 2 patients; combined AVR, MVR, and ventricular myotomy for hypertrophic obstructive cardiomyopathy in 1 patient; and AVR, MVR, and reconstruction of a tricuspid valve in 1 patient. Bioprosthetic valves were used in 2 patients in the aortic position and in 1 patient for MVR.

There were slight differences in the hemodynamic indices between group I and group II. Cardiac index, ejection fraction, and cardiac output were significantly lower in group II, while the mean pulmonary artery pressure was higher (see Table 3). The mean operating time was 173 ± 55 minutes (group 1, 175 ± 58 minutes; group 2, 170 ± 53 minutes), bypass time was 86 ± 34 minutes (group 1, 80 ± 28 minutes; group 2, 100 ± 43 minutes), and cross-clamping time was 49 ± 21 minutes (group 1, 41 ± 15 minutes; group 2, 67 ± 27 minutes). Intraoperative urine production ranged from 200 to 2,800 mL (945 ± 700 mL) and was significantly different between group I (1,195 ± 719 mL) and group II (472 ± 317 mL). Patients were extubated after a mean of 19 ± 21 hours postoperatively. Postoperative urine production was 3,030 ± 1,400 mL in the first 24 hours, and the drainage through chest tubes was 450 ± 260 mL.

Compared with the surviving patients, the patients who died had a significantly lower cardiac output (5.8 ± 1.4 versus 4.0 ± 0.2 L/min), a significantly lower cardiac index (3.3 ± 0.7 versus 2.2 ± 0.3 L • min^-1 • m^-1, a significantly longer cross-clamping time (70.5 ± 25.8 versus 46.3 ± 20.8 minutes), and a lower postoperative urine output (3,315 ± 1,260 versus 1,750 ± 1,525 mL) during the first 24 hours.

Serum creatinine and blood urea nitrogen returned to preoperative values after 5 postoperative days. Leukocytes were only slightly elevated on the fifth postoperative day, with no difference between group I and group II. No graft rejection episodes were observed.

At a mean follow-up of 44 ± 31 months, the cumulative 1-year patient survival was 88%; 5-year survival was 85%. Thirty-three patients were free of cardiac symptoms and returned to New York Heart Association classes I and II. Six patients in group I had return of angina on exertion. One patient after MVR and 3 patients after CABG had returned to hemodialysis at intervals of 27 to 83 months.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
In the past, the coexistence of organic heart disease and chronic renal failure represented a therapeutic dilemma. Patients with end-stage renal disease are well known to have a higher risk for coronary artery disease [11–13], and frequent arteriovenous access in these patients provides a potential entry for endocarditis [1, 11]. Less frequent lesions in these patients include valvular calcifications [14]. In patients with renal allografts, the risk of endocarditis is increased by immunosuppression therapy. It is believed that the greater risk of coronary heart disease is due to the greater incidence of systemic hypertension, diabetes, and hypertriglyceridemia, and diminished degradation of low-density lipoprotein [11–13, 15]. Patients after renal transplantation also have an accelerated form of atherosclerosis [1].

Renal transplantation and cardiac operation are both well-established procedures. However, few data are available about the risk and the mortality rate in patients after successful renal transplantation who undergo open heart operations. Several questions are still not answered in the literature: (1) Is the transplanted kidney able to cope with the massive trauma and the physiologic alterations associated with cardiopulmonary bypass? (2) Is there an increased risk of rejection, infection, and impairment of wound healing due to steroid treatment?

In 1975 and 1976, Lamberti and associates [3], Nakhjavan and colleagues [16], and Beauchamp and co-workers [17] published the first case reports concerning this issue. Other groups [18–21] also reported cardiac surgical procedures in patients after renal transplantation, although the numbers were limited. Bolman and colleagues [22] published the results of 14 patients. The operative aim in all of our patients was to reduce the incidence of cardiac-related death and to provide symptomatic improvement and a better life expectancy.

In the literature, the reported hospital mortality rates for patients with end-stage renal disease undergoing open heart operations range between 0% and 20% [12, 23–27]. Bolman and colleagues [22] reported a perioperative death rate of 14%. The overall mortality rate in our study was 8.8% (in-hospital, 11.1%), with a significant difference between group I (3.2%) and group II (21.4%; in-hospital, 28.6%). However, the severity of cardiac impairment, and therefore the general operative risk, in group II was also higher than in group I. Native valve endocarditis was a major risk factor; 3 of 4 patients with endocarditis died of sepsis after valve replacement. In our study, the overall cumulative patient survival was 88% for the first year and 85% at 5 years.

Patients undergoing CABG after successful renal transplantation had a 96.8% survival rate at 5 years. This exceeds the survival rates of dialysis patients [28] undergoing CABG (91.7%). After CABG, the New York Heart Association functional classification of most of our patients improved dramatically, as reported for dialysis patients [2, 79, 28] and for patients with normal renal function [27, 29]. As in dialysis patients, renal transplant recipients are more likely to require myocardial revascularization procedures than a valve replacement [1]. In our study, the ratio of CABG to valve replacements was 2:1; Bolman and colleagues [22] reported 11 CABG and only three valve operations. We generally preferred mechanical heart valves over bioprosthetic valves because of the young age (mean, 55 ± 11 years) of the patients and to avoid the increased risk of calcification as seen in patients with end-stage renal disease.

Serum creatinine and blood urea nitrogen levels in renal transplant recipients showed only a moderate rise postoperatively and returned in the majority of patients to preoperative values within the first 5 postoperative days. This is in agreement with the observations of Bolman and colleagues [22]. Consistent with others [3, 16, 18, 19], we saw no rejection episodes in our patients postoperatively. Obviously, the risk of rejection is not enhanced when immunosuppressive therapy is maintained throughout the perioperative period. Cardiac operations have many risk factors for sepsis, including major tissue trauma, prolonged exposure to air, and physiologic aberrations induced by the mechanical circulatory assist system. Despite all of these risk factors and immunosuppressive therapy, the incidence of wound infection or septicemia was comparable with that in patients not having transplantation. Only patients with endocarditis have a high risk of sepsis. Our study showed that renal transplant recipients can cope with the stress of cardiac operations. Only minimal disturbances in renal graft function were detectable. The risk of rejection is efficiently controlled by continuing the immunosuppression protocol.

We conclude that patients with functioning renal allografts undergoing open heart operations have acceptably low mortality and morbidity rates. Cardiac diagnostic studies and necessary open heart operations should be performed without delay when cardiac symptoms occur. Renal transplant recipients should be treated in the same manner as patients not having transplantation, with particular attention to maintaining kidney graft function by conventional therapeutic means.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Dresler, Department of Thoracic and Cardiovascular Surgery, Medizinische Hochschule Hannover, K.-Gutschow-Str 8, 30625 Hannover, Germany.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Zamora JL, Burdine JT, Karlberg H, Shenaq SM, Noon GP. Cardiac surgery in patients with end stage renal disease. Ann Thorac Surg 1986;42:113–7.[Abstract]
2. Chawla R, Gailiunas P Jr, Lazarus JM. Cardiopulmonary bypass surgery in chronic hemodialysis and transplant patients. Trans Am Soc Artif Intern Organs 1977;23:694–7.[Medline]
3. Lamberti JJ Jr, Cohn LH, Collins JJ Jr. Cardiac surgery in patients undergoing renal dialysis or transplantation. Ann Thorac Surg 1975;19:135–41.[Abstract]
4. Crawford FA Jr, Selby JH Jr, Bower JD. Coronary revascularization in patients maintained on hemodialysis. Circulation 1977;56:684–7.[Abstract/Free Full Text]
5. Lowe JW, Jahnke EJ, McFadden B. Myocardial revascularization in patients with chronic renal failure. J Thorac Cardiovasc Surg 1980;79:625–7.[Abstract]
6. Monson BK, Wickstrom PH, Haglin JJ. Cardiac operation and end-stage renal disease. Ann Thorac Surg 1980;30:267–72.[Abstract]
7. Zawada ET Jr, Stinson JG, Done G. New perspectives on coronary artery disease in hemodialysis patients. South Med J 1982;75:694–701.[Medline]
8. McGovern E, Rooney R, Neligan MC. Open heart surgery in patients receiving chronic dialysis. Thorax 1984;39:388–9.[Free Full Text]
9. Laws KH, Merrill WH, Hammon JW Jr, Prager RL, Bender HW Jr. Cardiac surgery in patients with chronic renal disease. Ann Thorac Surg 1986;42:152–7.[Abstract]
10. McNamee PT, Sombolos KI, David TE. Coronary artery bypass surgery in peritoneal dialysis patients. Periton Dial Bull 1986;6:128–30.
11. Rostand SG, Rutsky EA. Cardiac disease in dialysis patients. In: Nissenson AR, Fine RN, Gentile DE, eds. Clinical dialysis. East Norwalk, CT: Appleton & Lange, 1990:409–46.
12. Deutsch E, Bernstein RC, Addonizio VP, Kussmaul WG III. Coronary artery bypass surgery in patients on chronic hemodialysis: a case control study. Ann Intern Med 1989;110:369–72.
13. Rostand SG, Kirk KA, Rutsky EA. Relationship of coronary risk factors to hemodialysis associated ischemic heart disease. Kidney Int 1982;22:304–8.[Medline]
14. Depace NL, Rohrer AH, Kotler MN, Brezin JH, Parry WR. Rapidly progressive massive mitral anular calcification occurring in a patient with chronic renal failure. Arch Intern Med 1981;141:1663–5.[Abstract/Free Full Text]
15. Brown JJ, Dusredieck G, Fraser R. Hypertension and chronic renal failure. Br Med Bull 1971;27:128–35.[Free Full Text]
16. Nakhjavan K, Kahn D, Rosenbaum J, Ablaza S, Goldberg H. Aortocoronary vein graft surgery in a cadaver kidney transplant recipient. Arch Intern Med 1975;135:1511–3.[Abstract/Free Full Text]
17. Beauchamp GD, Sharma JN, Crouch T, et al. Coronary bypass surgery after renal transplantation. Am J Cardiol 1976;37:1107–10.[Medline]
18. Defraigne JO, Meurisse M, Limet R. Valvular and coronary surgery in renal transplant patients. J Thorac Cardiovasc Surg 1990;31:581–3.
19. Golan M, Goor DA, Jacob ET. Coronary artery bypass surgery in a cadaver kidney transplant recipient. Int Surg 1987;72:56–7.[Medline]
20. Ando M, Koyanagi H, Endo M, Nishida H, Hachida M, Teraoka S. A report of two cases of coronary bypass surgery after renal transplantation. Nippon Kyobu Geka Gakkai Zasshi 1993;41:2126–30.[Medline]
21. Yamamura M, Miyamoto T, Murata H, Kitai K, Ueda T, Wada T. A case of myocardial revascularization in a patient after renal transplantation. Nippon Kyobu Geka Gakkai Zasshi 1993;41:503–8.[Medline]
22. Bolman RM III, Anderson RW, Molina JE, et al. Cardiac operations in patients with functioning renal allografts. J Thorac Cardiovasc Surg 1984;88:537–43.[Abstract]
23. Batiuk TD, Kurtz SB, Oh JK, Orszulak TA. Coronary artery bypass operation in dialysis patients. Mayo Clinic Proc 1991;66:45–53.[Medline]
24. Francis GS, Sharma B, Collins AJ, Helseth HK, Comty CM. Coronary artery surgery in patients with end stage renal disease. Ann Intern Med 1980;92:499–503.
25. Blakeman BP, Sullivan HJ, Foy BK, Sobtka PA, Pifarré R. Internal mammary artery revascularization in the patient on long-term renal dialysis. Ann Thorac Surg 1990;50:776–8.[Abstract]
26. Ko W, Kreiger KH, Isom OW. Cardiopulmonary bypass procedures in dialysis patients. Ann Thorac Surg 1993;55:677–84.[Abstract]
27. Rostand SG, Kirk KA, Rutsky EA, Pacifico AD. Results of coronary artery bypass grafting in end stage renal disease. Am J Kidney Dis 1988;12:266–70.[Medline]
28. Opsahl JA, Husebye DG, Helseth HK, Collins AJ. Coronary artery bypass surgery in patients on maintenance dialysis: long-term survival. Am J Kidney Dis 1988;12:271–4.[Medline]
29. Johnson WD, Kayser KL, Pedraza PM. Angina pectoris and coronary bypass surgery: patterns of prevalence and recurrence in 3105 consecutive patients followed up to 11 years. Am Heart J 1984;108:1190–7.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christoph Dresler Thorsten Wahlers Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dresler, C. Articles by Borst, H.-G. Search for Related Content PubMed PubMed Citation Articles by Dresler, C. Articles by Borst, H.-G.