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Ann Thorac Surg 1997;64:1278
© 1997 The Society of Thoracic Surgeons
DR R. MORTON BOLMAN III (Minneapolis, MN):First of all, I congratulate Dr Mitruka and associates on a really outstanding group of results and Dr Mitruka on an excellent presentation. Your slides were very nice, and I congratulate you.
We have had an interest in this at the University of Minnesota. Although we do not do quite as many transplantations as you do, we do have all the organs represented. It is interesting how you sometimes find out the indications for transplantation in your center have changed and liberalized. I was asked recently to do an emergency coronary artery bypass procedure on a 74-year-old woman who 2 months before had undergone a liver transplantation, and I thought the upper age limit for the operation was about 60 years. But, be that as it may, these indications are changing. I would like to ask you a couple of questions.
In patients who go into the cardiac operation with an elevated creatinine level after kidney transplantation, we have noticed that many of those patients who go on dialysis are not able to come off it after operation. You had a similarly high incidence of permanent dialysis. Do you have any ideas, given this experience, regarding how to prevent that? You might want to respond to that first, because I have a couple other questions.
DR MITRUKA: Thank you, Dr Bolman, for your kind comments. Overall, 33% of kidney transplant recipients were in chronic renal failure and had serum creatinine levels greater than 3 mg/dL preoperatively. Of these 13 renal transplant patients, 7 required hemodialysis for acute renal failure postoperatively, of whom 3 ultimately lost their grafts. Although there is no certain way to prevent permanent allograft loss, the preoperative use of prophylactic hemodialysis in similar high-risk patients may prove of some benefit. Additionally, the maintenance of adequate hydration and perfusion pressures during cardiopulmonary bypass, judicious diuresis, and the routine intravenous administration of dopamine, mannitol, and furasomide may all promote early return of graft function postoperatively.
DR BOLMAN: Second, do you use any hemostatic adjuncts at the time of operation? I noticed you had a rather high incidence of returning to the operating room for bleeding. Are you using aprotinin or aminocaproic acid routinely, or sequestration?
DR MITRUKA: No hemostatic adjuncts such as aprotinin or aminocaproic acid are used routinely, as many of these patients already have marginal renal function, so administering aprotinin may exacerbate their renal impairment. The 16% incidence of mediastinal hematomas in patients that necessitated reoperations was unexplainably high in this population. It may be result from the presence of friable tissue stemming from long-term steroid use, and also from postcardiotomy platelet dysfunction. Chronic renal insufficiency may also contribute to the development of platelet dysfunction in certain patients. There were no episodes of coagulopathy, no excessive transfusion requirements, and no difficulty reversing heparinization in these patients. Intraoperatively, activated clotting times were maintained in the 400- to 600-second range, and results of coagulation studies postoperatively were considered normal. At reoperation no patient had an identifiable surgical cause for the bleeding. In the future, it may be prudent to prophylactically administer fresh frozen plasma and platelets to these patients to lower the incidence of this complication.
DR BOLMAN: And, finally, it was not entirely clear to me from the manuscript, but did you notice any difference in the mortality or morbidity rate from the standpoint of when the cardiac operation took place relative to the time of transplantation? It has been our observation that, when patients are under the effects of the intensive immunosuppressive treatment that they receive early after their transplantation, they are at higher risk for wound complications and infections particularly. Has that been your observation?
DR MITRUKA: We were not able to correlate the time from transplantation to cardiac operation with an increase in morbidity or mortality. As examples, in 1 patient, angina developed in the intensive care unit the evening after her kidney transplantation and she required three-vessel coronary artery bypass grafting the next morning with an outstanding result, whereas 2 other patients had had their grafts in place for more than 10 years and died of sepsis after their cardiac procedures. So, the time interval from transplantation to cardiac operation as an independent variable appeared to have no correlation with the incidence of infectious or noninfectious complications, recognizing the limitations of drawing definitive conclusions from a relatively small sample size.
Related Article
Ann. Thorac. Surg. 1997 64: 1270-1278.
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