Ann Thorac Surg 2003;76:478-481
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Cardiac valve replacement in human immunodeficiency virus–infected patients
Tec Chong, MDa,
Diane E. Alejo, BAa,
Peter S. Greene, MDa,
J. Mark Redmond, MDa,
Marc S. Sussman, MDa,
William A. Baumgartner, MDa,
Duke E. Cameron, MDa*
a Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
* Address reprint requests to Dr Cameron, Division of Cardiac Surgery, Blalock 618, The Johns Hopkins Hospital, 600 North Wolfe St, Baltimore, MD 21287, USA
e-mail: dcameron{at}jhmi.edu
Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
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Abstract
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BACKGROUND: Valve replacement in human immunodeficiency virus (HIV)-infected patients is being performed with increasing frequency, but the early and late results in these immunocompromised patients are not known.
METHODS: A 10-year retrospective clinical review was undertaken; patients and their physicians were contacted for follow-up clinical status.
RESULTS: Twenty-two HIV-infected patients underwent valve replacement between 1990 and 1999, with no operative or hospital deaths. Mean patient age was 37.6 years; 15 were men. Indications for operation were heart failure in 59% (13/22) and sepsis in 91% (20/22). There were 12 aortic valve replacements, seven mitral valve replacements, and three double valve replacements. Mechanical valves were used in 11, bioprostheses in seven, and homografts in four. Follow-up information was available in 20 of 22 patients (84%). At mean follow-up of 5 years, there were 10 late deaths, due to: intracerebral hemorrhage (2), heart failure (2), unknown cause (2), renal failure (1), AIDS (1), sepsis (1) and endocarditis (1). Of the 20 patients with active preoperative endocarditis, 4 (20%) developed recurrent endocarditis; freedom from recurrent endocarditis was 83% at 1 year. Intravenous drug abuse was reported in 16 patients; survival among these patients was 94% at 1 month and 50% at 5 years. Recurrent endocarditis was only seen in patients with continued intravenous drug abuse.
CONCLUSIONS: Valve replacement in HIV-infected patients has low operative risk, but late results are poor when HIV infection is associated with intravenous drug abuse, probably due to immunocompromise and continued high-risk behavior.
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Introduction
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Patients with human immunodeficiency virus (HIV) infection have been regarded by some surgeons to be poor candidates for cardiac surgery, in part due to a perception of poor overall prognosis, but objective information on surgical outcomes in these patients has been limited. This study set out to determine the early and late mortality and morbidity of valve replacement among HIV-infected patients in order to provide guidelines for management.
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Material and methods
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Study population
Patients with HIV infection who underwent cardiac valve replacement surgery were identified from the Johns Hopkins Hospital Cardiac Surgery database, a computerized record of more than 17,000 cardiac surgical patients operated on since 1983. The study was limited to the most recent 10 years of experience (1990 to 1999). Prior cardiac surgery was not an exclusionary criterion.
Data collection
Hospital charts were reviewed for preoperative, intraoperative, and postoperative variables. Patients or their physicians were contacted by telephone for follow-up information with regard to survival, major late complications, recurrent endocarditis, and further cardiac surgery.
Statistical analysis
Survival and freedom from complication were calculated using the Kaplan-Meier method incorporated in SPSS for Windows software (SSPS Inc, Chicago, IL).
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Results
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Patient characteristics
Twenty-two HIV-infected patients were identified; 15 (68%) were men and 7 (32%) were women. Nineteen (86%) were African-American and 3 (14%) were white. Mean age at operation was 37.5 years. Sixteen patients (73%) had a history of intravenous drug abuse (IVDA). CD4 counts were only available in 2 patients. The duration of HIV infection was not determined, nor was an attempt made to define whether patients had the clinical syndrome of aquired imunodeficiency syndrome (AIDS). It was difficult to ascertain whether operation was denied for other HIV-infected patients during the period of the study, but HIV infection per se is not regarded as a contraindication to surgery in our institution. It is possible that some patients not reported here were denied operation because of moribund clinical status or prosthetic valve infection related to recidivist IVDA.
Valve involvement
The aortic valve was the most commonly involved valve in this group of surgically treated patients; as an isolated lesion, it accounted for 47% of all cases (Fig 1).
Isolated mitral involvement was the second most common (32%), whereas combinations of aortic, mitral, and tricuspid disease accounted for the remaining cases.
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Fig 1. Valves involved by endocarditis. White = aortic; dark gray = mitral; light gray = aortic and mitral; black = aortic and tricuspid; light gray without border = mitral and tricuspid.
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Infecting organisms
Staphylococcal organisms were responsible for 43% of all endocarditic infections and Streptococcus made up 29%. Pseudomonas and Haemophilus species each accounted for 4%.
Indications for surgery
Nearly all patients (20/22, 84%) had either a remote history of endocarditis or active endocarditis at the time of surgery. Sixteen of 22 (73%) had active endocarditis and clinical sepsis as the primary indication for surgery (Fig 2).
In the remaining 8 patients (27%), congestive heart failure from mitral or aortic insufficiency was the primary indication for surgery.
Operative procedure
Aortic valve replacement was the most common surgical procedure (12/22, 40%). Seven mitral valve replacements (7/22, 32%) and three combined aortic and mitral valve replacements (3/22, 14%) were performed. Mechanical prostheses were used in 60% (13/33) of patients, stented xenograft prostheses in 32% (7/22), and cryopreserved aortic homografts in the remaining 3 patients (18%). Homografts were always used as full root replacements, usually because of extensive root destruction by invasive infection. The choice of prosthesis was determined by surgeon and patient, and usually reflected patient’s preference with regard to anticoagulation and anticipated compliance.
Operative outcome
There were no operative or hospital deaths. Three serious postoperative complications occurred in 3 patients: one early postdischarge fatal hemorrhagic stroke in the setting of therapeutic anticoagulation (patient 5, Table 1),
one case of persistent congestive heart failure, and one case of stubborn atrial flutter. There were no early infections and no mediastinal reexplorations for hemorrhage.
Survival
There were 10 late deaths (10/22, 45%). Two patients were lost to follow-up. Causes of death are detailed in Table 1. Overall group survival was 40% at 5 years, and 20% at 10 years for the group overall. In the subset of IVDA, there were no survivors beyond 8 years (Fig 3).
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Fig 3. Survival after valve replacement in HIV-infected patients according to history of IVDA. (Hx = history; IVDA = intravenous drug abuse.)
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Endocarditis and intravenous drug use
Of 20 patients with preoperative endocarditis, only 5 (25%) developed recurrent endocarditis after valve replacement. All 5 of these patients had continued IVDA postoperatively. The original and "reinfecting" organisms in these 5 patients are shown in Table 2.
No episodes of postoperative endocarditis occurred in any HIV-infected patient who remained free of IVDA.
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Comment
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HIV infection may involve multiple organ systems, including lung, brain, skin, gastrointestinal tract, kidneys, and heart [1]. Cardiac involvement may be manifest in several ways: pericardial disease (tamponade or constriction related to neoplasm), myocardial disease (through neoplastic infiltration or myocarditis), and endocardial disease (endocarditis) [2]. The most serious cardiac involvement is infectious endocarditis, which may be acquired from nonspecific immunocompromise or from the same high-risk behaviors that lead to HIV infection. Studies report a relatively low incidence of spontaneous endocarditis among HIV patients without IVDA; interestingly, the clinical manifestations of endocarditis in these patients have been nonspecific [3, 4]. In our study group, patients were frequently afebrile and had normal white cell counts. This may reflect the depressed immune status of individuals unable to mount a normal neutrophilic response.
Whether HIV-infected patients with endocarditis respond favorably to traditional medical and surgical interventions has received little study [4, 5]. This study shows that these patients initially respond well to standard surgical therapy, specifically valve replacement with conventional prostheses, and that operative mortality and morbidity are low. However, the mid- and late-term results were disappointing. We had speculated that HIV-infected patients would be at risk for recurrent endocarditis because of immunocompromise or, in some, because of continued "high risk" behavior, such as IVDA. Our results suggest that only the latter is true; indeed, no episodes of recurrent endocarditis occurred unless there was continued IVDA after operation, and recurrent endocarditis was frequently due to a new organism. Furthermore, continued IVDA was highly lethal: all patients who continued IVDA were dead within 10 years.
The selection of valve prostheses is always problematic among patients with limited life expectancy, immunocompromise, and poor compliance with medical therapy. There were insufficient data from this study to support use of bioprostheses over mechanical prostheses. However, the two instances of fatal intracerebral hemorrhage raise concern over the risk of anticoagulation, especially in a group of patients who may harbor subclinical intracerebral mycotic aneurysms [6, 7]. On the other hand, our experience with valve replacement for endocarditis in IVDA patients has been that patients who continue IVDA have extraordinary high mortality regardless of their valve prosthesis; in contrast, those who cease IVDA do very well, and should not be "punished" by need for reoperation on degenerated bioprostheses.
In summary, valve replacement surgery can be performed in HIV-infected patients with low operative risk without increased risk of reinfection or recurrent endocarditis unless IVDA persists. However, long-term survival remains poor, in part because of continued IVDA and possibly because of other medical conditions associated with HIV infection.
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Discussion
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DR GREGORY TRACHIOTIS (Washington, DC): Doctor Cameron, that was a great presentation, and the Mid-Atlantic is very well represented with this topic. You hinted at it during your presentation, as well as in your conclusion: our philosophy in these patients has been to prove that they will be compliant or clean their act up, if you will, and therefore, our policy is to place bioprosthetic valves (in general). And I would like to know if you have come up with a policy or a rationale for these type of patients?
DR CAMERON: We do not have a formal policy, and thank you very much, Greg, for your comments as well. It has been our tradition to offer bioprosthetic valves to most of these patients because of our concerns about their compliance with anticoagulation.
This argument has not been totally embraced by our division, but I think it is an interesting argument, and I think just points out that it is still a very complex issue. For the time being, I think the decision is still made on a patient-by-patient basis. These are patients who can still participate in decisions about their health care.
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References
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- Thuesen L., Nikker A., Kristensen B.O. Cardiac function in patients with human immunodeficiency virus infection and with no other active infections. Dan Med Bull 1994;41:107-109.[Medline]
- Kaul S., Fishbein M.C., Siegel R.J. Cardiac manifestations of acquired immune deficiency syndrome: a 1991 update. Am Heart J 1991;122:535-544.[Medline]
- Rivera Del Rio J.R., Flores R., et al. Profile of HIV patients with and without bacterial endocarditis. Cell Mol Biol 1997;43:1153-1160.
- Currie P.F., Sutherland G.R., Jacob A.J., et al. A review of endocarditis in acquired immunodeficiency syndrome and human immunodeficiency virus infection. Eur Heart J 1995;16(Suppl B):15-18.
- Bayer A.S., et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998;98:2936-2948.[Free Full Text]
- Edmunds L.H. Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987;44:430-445.[Abstract]
- Gillinov A.M., Shah R.V., Curtis W.E., et al. Valve replacement in patients with endocarditis and acute neurologic deficit. Ann Thorac Surg 1996;61:1125-1129.[Abstract/Free Full Text]
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Abstract
Introduction
