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Ann Thorac Surg 2000;70:813-818
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
Address correspondence to Dr Kratz, Department of Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425
Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Association, San Juan, Puerto Rico, Nov 4–6, 1999.
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Abstract |
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Methods. The operative, early postoperative, and late results of 44 dialysis patients undergoing coronary artery bypass grafting from 1984 to 1997 were retrospectively reviewed.
Results. Compared with patients in The Society of Thoracic Surgeons database who underwent coronary artery bypass grafting, only cerebrovascular accident and postoperative cardiac arrest occurred more frequently in dialysis patients. However, 73% experienced some type of complication. Operative mortality was 11.4%. Decreased left ventricular ejection fraction and severe distal disease were predictive of increased operative mortality. New York Heart Association angina class fell from 2.8 to 1.5, and New York Heart Association congestive heart failure class fell from 2.6 to 1.8. Overall quality-of-life scores did not improve; however, walking distances remained consistently improved. Actuarial survival at 5 years was 32.0% ± 12.0%. Five-year survival was 0% for smokers and 83.6% ± 7.6% for nonsmokers (p = 0.0142). Causes of late death were myocardial infarction (4), sepsis (1), subdural hematoma (1), stroke (1), and unknown (6).
Conclusions. Coronary artery bypass grafting should be avoided in dialysis patients with severe diffuse disease. A smoking history is associated with poor outcome. Coronary artery bypass grafting in dialysis patients is associated with a higher incidence of complications but can be performed with an acceptable operative mortality and is associated with good symptomatic relief of angina and heart failure.
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Introduction |
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The morbidity of cardiac disease also remains problematic for the chronic renal failure patient. Dialysis may be interrupted or limited by episodes of hypotension or angina. Renal transplantation has been documented to lessen complications associated with renal failure. Coronary artery disease is usually present at the beginning of dialysis therapy [4] and usually has progressed further by the time of consideration for transplantation. This underlying coronary artery disease must frequently be addressed to allow uncomplicated dialysis or before the transplantation to assure a successful result uncomplicated by myocardial infarction.
Approximately two thirds of chronic renal failure is caused by diabetes mellitus or primary hypertension. These same diseases frequently result in severe cardiovascular disease. As with diabetes, however, chronic renal failure patients frequently present with a more virulent and aggressive form of atherosclerotic disease characterized by diffuse disease throughout the coronary arteries and a vasculopathic state involving the entire body. Can coronary artery bypass grafting (CABG) make a successful impact on the morbidity and mortality of this disease? Can CABG be performed with a low enough morbidity and mortality to be a useful tool in the treatment of cardiovascular disease in patients with chronic renal failure?
Our previously reported [5] successful short-term experience performing six CABG procedures and six valve replacements on patients with chronic renal failure with an overall operative mortality of 8.3% has led to an increased use of CABG in patients with chronic renal failure (Fig 1). Our more recent short- and long-term results with isolated CABG in patients maintained on chronic dialysis are reported.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Follow-up was 100% complete. Follow-up was accomplished by phone, when possible, with the patient and, if not available, with primary caregivers, dialysis nurses, or referring physicians. All hospital charts for the surgical admission were reviewed, along with death certificates when necessary. Operative death was defined as death occurring within 30 days of operation or during same hospital stay. Quality of life during follow-up was recorded using a numerical scoring system. Preoperative angiograms from each patient were blindly reviewed by a single physician (J.M.K.) and graded for degree of diffuse disease with a numerical score. Early operative mortality and perioperative complications were recorded and compared with results from The Society of Thoracic Surgeons (STS) database for 1997 [6] and our own database for all CABG patients for 1994 through 1997. Although we would have preferred to compare the dialysis patients with our entire CABG patients for the same period, data for all CABG patients at our institution for 1984 through 1993 were not available. Short- and long-term results examined included change in anginal class, heart failure, and quality of life.
Statistical analysis
Continuous variables are reported as the mean ± standard error, and categorical variables are presented as percentages. Univariate comparisons of continuous data were made with the Student’s t test. Proportions were compared univariately with the 
2 statistic and Fisher’s exact test as appropriate. Univariate late-survival estimates were calculated using the Kaplan-Meier technique and are reported with the standard error of the estimate. Comparisons of survival estimates among subgroups were performed with the Mantel-Cox (log-rank) test. The Cox proportional hazards model was used to examine predictors of late death. Prognostic indicators of operative mortality were evaluated using logistic regression. Patients assigned diffuse disease scores were analyzed as a subgroup of the total sample. All statistical analyses were performed with the BMDP statistical software package, edition 1988 (University of California Press, Berkeley, CA).
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Results |
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Early results
Frequency of complications was compared with the overall frequency of complications from the STS database from 1997 and our own complete group of CABG patients from 1994 through 1997 (Table 1). Cerebrovascular accident (7% versus 1.7%; p = 0.0355) and cardiac arrest (7% versus 1.5%; p = 0.0195) occurred significantly more often in this group compared with the STS database. The percentage of dialysis patients experiencing some type of complication compared with the 1997 STS database for first-time CABG patients was also greater (73% versus 36%; p 
0.0001). The incidence of some type of complication was also significantly greater when compared with our overall group of CABG patients (73% versus 32%; p 0.0001; Table 1).
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We inquired as to quality of life during preoperative, early postoperative, and later postoperative periods. A scale similar to the New York Heart Association system was used. A numerical scoring system rating overall quality of life as perceived by the patient was explored: I, full life without restrictions; II, minimally restricted, able to carry out almost all normal daily activities; III, moderately restricted, unable to do any but lightest daily activities; and IV, bed or wheelchair bound, unable to care for self. Average quality-of-life score remained fairly constant through the preoperative, early postoperative, and late postoperative course (2.2 ± 0.2 preoperatively, 1.9 ± 0.2 on early follow-up, 2.1 ± 0.3 in late follow-up after complete recovery from operation). Patients were also evaluated for change in walking distance. Eighty-two percent noted improvement in walking distances in early follow-up. On long-term follow-up, 24 of 26 patients continued with good walking capability, whereas 2 had become wheelchair bound.
Of those patients surviving operation, 10 of 39 (25.6%) experienced subsequent cardiac events that led to hospitalization. Congestive heart failure was the most common cause. Myocardial infarction caused late hospitalization in 2 and the death of 1 patient. One patient is particularly illustrative of the problem of distal coronary disease. She underwent cardiac catheterization 20 months after operation for recurrent angina with the finding of four of four grafts widely patent. Distal arteries were diffusely diseased. She died 4 months later from coronary ischemia.
At 5 years, there had been 18 deaths from the total of 44 patients. Actuarial overall survival at 5 years was 32.0% ± 12.0% (Fig 2). The only risk factor associated with late death on univariate and multivariate analysis was history of smoking (Table 4; p = 0.012). The 5-year survival was a striking 0% for smokers (6 deaths, 9 patients) and 83.6% ± 7.6% for nonsmokers (7 deaths, 29 patients; Fig 3). Causes of late death were myocardial infarction (4), sepsis (1), subdural (1), stroke (1), and unknown (6). A history of heavy alcohol use preoperatively was a risk factor for late death on univariate but not multivariate analysis (p = 0.0414; p = 0.7290, respectively). No other risk factor was a significant predictor of late death; however, our sample size may have been too small to detect existing differences.
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Comment |
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The cerebrovascular accident rate of 7% was greater than the STS database rate of 1.7% and was similar to other reported series of dialysis patients: Kaul and coworkers [9], 11%; Marshall and associates [10], 8%; Christiansen and colleagues [7], 6%; and Blum and associates [11], 8%. Cerebrovascular accident is a frequent cause of death in dialysis patients, falling only behind cardiovascular disease and sepsis as a cause of death in dialysis patients [12]. It is unclear whether the strokes in these CABG patients were caused by embolism, lower perfusion pressures on cardiopulmonary bypass, or carotid vascular obstructive disease. Reasonable steps to improve these results might include more liberal use of aortic ultrasound examination before cross-clamping, increased perfusion pressure on bypass, and routine noninvasive carotid artery screen before operation.
Postoperative bleeding has been recognized as a common problem after CABG in dialysis patients. Our rate of 7% is again higher than the STS database rate of 2.2% and is in line with previous reports: Blakeman and associates [13], 8%; Batiuk and coworkers [14], 5%; Opsahl and colleagues [15], 3%; Marshall and associates [10], 0%; and Jahangiri and coworkers [16], 11%. Interestingly, 2 of our 3 patients with postoperative bleeding occurred in our first 12 patients and before 1991. We have routinely used aminocaproic acid prophylactically in recent years, with a recent reoperation for bleeding rate of 1 of 31 (3%). With use of aminocaproic acid or possibly aprotinin in these patients, postoperative bleeding rates should approach usual CABG rates. We have no experience with desmopressin acetate, although it has also been suggested to be a useful tool in these patients [17–19].
A total complication rate of 74% for our dialysis patients compared with 33% in the STS database makes clear the need for continued improvements and refinement in techniques to lower complication rates. Poorer rate of prevention of cardiac event and death in angioplasty patients suggest these patients have a form of disease resistant to success with angioplasty technique [20]. Therefore, continued CABG in these patients with optimized techniques to lower complications is indicated. Many of the complications associated with CABG in dialysis patients may be related to the use of cardiopulmonary bypass (bleeding, fluid overload, cerebrovascular accident). Our early and limited experience in 2 recent patients with renal failure and off-pump cardiopulmonary bypass suggests this may be a good approach for these complex patients.
Our operative mortality rate of 11.4% fits within the widely variable range of previous reports: Opsahl and associates [15], 2.6%; Deutsch and colleagues [8], 6.0%; Blum and coworkers [11], 15%; Rostand and associates [21], 20%; and Batiuk and coworkers [14], 20%. Previous reports have found a correlation between New York Heart Association congestive heart failure class and operative mortality [9, 11]. Batiuk and colleagues [14] noted a strong relationship for recent preoperative myocardial infarction with operative death. Although we noted a higher mortality in patients with congestive heart failure class III or IV (13%; 3 of 23) versus class I or II (10.5%; 2 of 19), this did not reach statistical significance in our sample size of 44 patients. As noted, ejection fraction was a significant predictor of operative mortality in our group of dialysis patients.
Jahangiri and coworkers [16] suggested that diffuse coronary artery disease, frequently found in dialysis patients, was a predictor of operative mortality. In our series, operative mortality was increased in patients with more diffuse disease. It is our clinical observation that dialysis patients may present with two different patterns of coronary artery disease. Some present with typical proximal obstructions and reasonably good distal vessels; however, a second group will present with severe distal disease in addition to proximal obstruction. Given the increased operative risk and the decreased chance for benefit from operation, this second group should, in most instances, receive medical therapy or angioplasty when possibly helpful.
The great majority of our patients enjoyed excellent relief of angina immediately after operation. More gratifying was the term maintenance of freedom from angina on long-term follow-up, confirming the results of De Meyer and associates [22], Kaul and coworkers [9], Opsahl and colleagues [15], and Blum and collaborators [11] demonstrating the success of CABG in accomplishing its first goal of relieving angina. This result was especially important to our patients, who preoperativly were having great difficulty undergoing dialysis because of angina.
We were further gratified to find the persisting improvement in congestive heart failure status. We do not have late ejection fraction data to further elucidate the mechanism of this improvement. This may be the result of relief of the anginal equivalent of shortness of breath masquerading as congestive heart failure or actual improvement of ventricular function.
Quality of life is difficult to evaluate or improve in patients bound to dialysis machines three times a week and who also suffer from other complications of chronic renal failure. Thus, one might expect to see less improvement in overall quality of life than with more cardiac-specific complaints such as angina or congestive heart failure after CABG. Although mean quality-of-life scores did not improve, at least walking distance and thus independent mobility was improved by CABG.
Analysis of long-term survival yielded somewhat surprising and unreported results. Bad habits were particularly damaging to our patients. On univariate analysis, a history of alcohol use was statistically predictive of a poorer long-term survival. Most striking was the marked difference in smoker and nonsmoker survival. With these data, we must redouble our efforts to persuade our dialysis patients to give up these toxins. Conversely, the 84% 5-year survival for the nonsmokers demonstrates the possibility for good results in this chronically ill and complex group of patients.
Coronary artery bypass grafting can be performed on dialysis patients with acceptable morbidity and mortality. Relief of angina is excellent and persists over time. Coronary artery bypass grafting should be offered to dialysis patients whose angina is not relieved with medical management. Dialysis patients with severe diffuse disease in two or three vessels are less acceptable candidates for operation and are at high risk for operative mortality if managed surgically.
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