Cardiac Surgery in Patients Infected with Human Immunodeficiency Virus

Abstract

From January 1991 through December 1999, 5 consecutive patients who were infected with human immunodeficiency virus presented in need of cardiac surgery. All were men; the median age was 44 years. Two of them presented with mitral and aortic infectious valve endocarditis, 1 with tricuspid endocarditis, 1 with prosthetic valve endocarditis, and 1 with pericarditis and pericardial tamponade.

Under cardiopulmonary bypass, the 4 patients with endocarditis underwent these procedures: mitral and aortic valve replacement (2), tricuspid valve replacement (1), and aortic valve replacement (reoperation) and concomitant repair of a mycotic ascending aortic aneurysm (1). In the patient who had pericardial effusion, subxifoid pericardiostomy and drainage were performed, and a pericardial window was created.

There was no intraoperative mortality. The patient with pericardial effusion died 8 days after surgery; he was in septic shock and had multiple organ failure. Two deaths occurred at 2 and 63 months, due to hemoptysis and sudden death, respectively. The 2 patients who underwent double valve replacement are alive and in good condition after a median follow-up of 71 months.

Cardiac surgery is indicated in selected patients infected by the human immunodeficiency virus. These patients are frequently drug abusers or homosexual. Valvular endocarditis is the most common finding. Hospital morbidity and mortality rates are higher than usual in this group of patients.

Despite continuing advances in cardiac surgery, the number of adult patients infected with human immunodeficiency virus type 1 (HIV-1) presenting in need of heart surgery is relatively restricted. The study presented herein represents our experience in cardiac surgery with 5 patients infected with HIV-1. Four of these patients underwent surgery with the assistance of cardiopulmonary bypass (CPB).

Patients and Methods

From January 1991 through December 1999, 3,151 cardiovascular operations were performed in our unit (1,525 open-heart procedures, 355 closed-heart operations, and 1,271 peripheral vascular procedures). Among these, 5 HIV-positive patients underwent cardiac surgery. The 5 patients were men with a median age of 44 years (range, 34 to 57 years). Three of them were addicted to intravenous drugs and 2 were homosexual (Table I).

TABLE I. Preoperative and Operative Data in the 5 HIV-Infected Men Undergoing Cardiac Surgery

Diagnoses were made by general and cardiac evaluation, including transthoracic echocardiography and transesophageal echocardiography in 3 (patients 2, 4, and 5). Four patients had endocarditis: 2 had mitral and aortic valve endocarditis, 1 had prosthetic aortic valve endocarditis and mycotic aortic root aneurysm, and 1 had tricuspid valve endocarditis with pulmonary embolism. The 5th patient had pericarditis with severe pericardial effusion. The causal organisms were Streptococcus viridans, Enterococcus fecalis, Candida albicans, Staphylococcus epidermidis, and Mycobacterium tuberculosis (Table I). Of the 4 patients with infectious valve endocarditis, 3 presented with fever, heart failure, positive blood cultures, and echocardiographic signs of severe aortic valve insufficiency; 2 had vegetations; and 1 had tricuspid insufficiency with pulmonary embolism. The patient with pericarditis and pericardial effusion had fever, sepsis, congestive heart failure, and cardiac tamponade. All patients were in New York Heart Association (NYHA) functional class III or IV. The HIV infection was shown in all 5 patients by enzyme immunoassay and confirmed by Western blot technique. The 5 patients were cared for before and after surgery by the same medical team, using specific antibiotics.

Cardiac surgery in the 4 patients with infectious valve endocarditis was begun through a median sternotomy incision using standard techniques, with CPB and myocardial preservation. The following operations were performed: 2 cases of aortic valve replacement (AVR) and mitral valve replacement (MVR) with Carbomedics mechanical bileaflet valves (Sulzer Carbomedics; Austin, Tex); 1 case of AVR reoperation with a Carbomedics aortic heart valve and concomitant repair of a mycotic ascending aortic aneurysm with a Dacron patch; and 1 case of tricuspid valve replacement (TVR) with a Hancock® bioprosthetic heart valve (Medtronic, Inc.; Minneapolis, Minn). The patient with pericardial effusion was treated by pericardial paracentesis followed by subxifoid pericardiostomy, drainage of pericardial effusion (650 mL), partial pericardiectomy, and creation of a pericardial window (Table II).

TABLE II. Preoperative, Surgical, and Postoperative Data in the 5 HIV-Infected Men Undergoing Cardiac Surgery

In all patients, the diagnosis was confirmed by postoperative microbiologic investigation of specimens removed at surgery. In patient 1, S. viridans was found in the aortic and mitral leaflets and also in vegetations. In patient 2, there was C. albicans in the leaflets and vegetations of the tricuspid valve. In patient 3, S. epidermidis was found in the dysfunctional aortic bioprosthesis. In patient 4, there was M. tuberculosis in the pericardium and pericardial fluid. In patient 5, E. fecalis was observed in the excised native mitral and aortic valves and vegetations.

Results

All patients survived the surgical procedure. Of the 2 patients who underwent concomitant AVR and MVR, patient 1 is in NYHA functional class I after 116 months (according to his local physician), and patient 5 is in functional class II after 26 months (Table II). Patient 2, who underwent TVR, was discharged from the hospital but died 2 months postoperatively of massive hemoptysis. The autopsy showed pulmonary cavitation and hemorrhage from the upper lobe of the right lung. The bioprosthetic tricuspid valve was normal. Patient 3, who underwent reoperative AVR and repair of a mycotic aortic root aneurysm, was in functional class I and enjoyed a normal life for 63 months after surgery. However, he died suddenly at home, and no postmortem examination was performed. The patient who had pericardial drainage (patient 4) died in the intensive care unit, 8 days after surgery, of septic shock and multiple organ failure.

Discussion

The routine use of increasingly intensive antiretroviral therapies has led directly to dramatic declines in morbidity and mortality among HIV-1-infected patients with advanced immunodeficiency (CD4⁺ count <100 cells/mm³). ¹ Mortality declined from 29.4 per 100 person-years in 1995 to 8.8 per 100 person-years in mid 1997. A number of patients infected with HIV-1 may develop cardiovascular diseases or complications and require cardiac surgery. Endocarditis is relatively common complication in patients infected with HIV and in intravenous drug users: these patients may need valve repair, replacement, or both. ^1,2

Good results have been achieved with the use of mechanical heart valves, ³ bioprosthetic valves, ⁴ and homografts ⁵ in patients who have endocarditis. We use the following standards for heart valve replacement: in general, we tend to use a mechanical heart valve in adults, young patients, pediatric patients, and in those who have no contraindication to long-term anticoagulation. A bioprosthetic valve is implanted in most patients over 65 or 70 years, patients with proven short life expectancy, those requiring right-heart valve replacement, those in whom anticoagulation poses a high risk, and those with contraindications to long-term anticoagulation. The same policies are applied to patients who are HIV positive, whether they use intravenous drugs or not. We explain our general recommendations to our patients, along with the advantages and disadvantages of each heart valve prosthesis, and allow the patients to make the final decision. Surgery for aortic valve endocarditis using homografts is also a useful alternative in patients addicted to intravenous drugs or infected with HIV. ⁶ In patient 3, total aortic root replacement with a homograft might have been successful. However, we decided to perform AVR with a mechanical valve and patch repair with a fabric graft. The results were excellent. At our institution, the application of cardiovascular substitutes using human cryopreserved homografts is generally restricted. ^7,8

In Spain, the law does not permit routine testing for HIV-1 infection in all surgical candidates. Therefore, it is possible that we have performed surgery on HIV-positive patients without our knowledge. Our 5 patients were HIV-1 carriers, which they knew before admission to our hospital; we confirmed the diagnosis. We know of no incident of transmission of the HIV infection to the surgical staff or nurses by needle puncture or injury during surgery, or to any other caregivers involved with these patients.

Frater ^9–12 was one of the 1st cardiothoracic surgeons to focus attention on HIV-1-infected patients who needed heart surgery. In a review of the English medical literature about cardiac surgery in patients infected with HIV-1, we found several reports of such cases (Table III). ^10,13–20 Hospital mortality rates ranged from 0% to 40%. Some of those patients were intravenous drug addicts or homosexual, and infectious valve endocarditis was a frequent finding. According to some authors, ^13,16 heart surgery with CPB does not seem to accelerate immunodeficiency or to produce adverse effects on patients with HIV-1 infection. Cardiac surgery in HIV-infected patients is complicated by higher mortality and morbidity rates in comparison with patients who are not infected with HIV-1. This group of high-risk patients has the following characteristics: 1) immunodepression, 2) poor general condition, 3) high numbers of associated diseases and infections, 4) a high proportion of intravenous drug addicts, homosexuals, and bisexuals, 5) high rates of infectious valve endocarditis, 6) frequent recurrence of infection after surgery, 7) unsatisfactory long-term results, and 8) increased chance of transmission of HIV-1 to the surgeon and clinical staff.

TABLE III. Selected Data from References about Cardiac Surgery in HIV-Infected Patients

According to Klatt, ²¹ the risk of accidental infection to operating room personnel through blood contact during surgical procedures is not excessive and can be reduced by adherence to universal precautions. As other groups have done, our surgical team has adopted special precautions; we use impermeable gowns, 2 pair of surgical gloves, protective glasses, and reinforced masks.

Due to the increased life expectancy that is being reported ^1,2 for medically treated patients with HIV-1 infection, this disease is considered today to be a chronic illness. For this reason, it is reasonable to expect an increasing number of patients infected with HIV-1 to present in need of surgery for heart complications, or for accompanying acquired cardiovascular diseases such as coronary artery disease, valve disease, aneurysms, and others that are amenable to surgical treatment. Cardiovascular surgeons should be prepared to receive these patients.