Asian Cardiovasc Thorac Ann 2001;9:45-47
© 2001 Asia Publishing EXchange Pte Ltd
Complicated Cardiac Surgery in Renal Transplant Patient
Hitoshi Hirose, MD,
Atsushi Amano, MD1,,
Akihito Takahashi, MD,
Naoko Nagano, MD1,
Department of Cardiovascular Surgery Kobari General Hospital Chiba, Japan
1 Department of Cardiovascular Surgery Shin-Tokyo Hospital Chiba, Japan
|
|
|
For reprint information contact: Hitoshi Hirose, MD Tel: 81 471 24 6666 Fax: 81 471 24 6764 email: genex{at}mb.infoweb.or.jp Department of Cardiovascular Surgery, Kobari General Hospital, 29-1 Yokouchi, Noda City, Chiba 278-8501, Japan.
|
 |
Abstract
|
|---|
Concomitant mitral valve repair, maze procedure, and coronary artery bypass grafting were carried out in a renal transplant recipient. The operation was complicated by intraoperative iatrogenic ascending aortic dissection that was successfully repaired.
|
Introduction
|
|---|
Patients with renal failure carry high risks of both coronary artery and cardiac valvular disease. These are major causes of death in patients with endstage renal failure (ESRD) and more than one-third of patients with ESRD die from cardiac causes.1 On the other hand, patients with ESRD but no coronary lesions are known to have almost the same cardiac mortality rate as the general population.2 Cardiac surgery has been performed in patients with ESRD with minimally increased perioperative risks.3 The recipients of renal transplants are more prone to infection because of immunosuppression, and their electrolyte-water balance is based on narrow thresholds. Although special attention must be paid to infection and fluid balance, surgical intervention can improve the patient's quality of life and long-term survival.4 A case of combined mitral valve repair, maze procedure, and coronary artery bypass grafting (CABG) in a renal transplant patient is described.
|
Case Report
|
|---|
A 48-year-old woman who had received a cadaver renal transplant 6 years previously for chronic glomerulonephritis, and who developed congestive heart failure, was admitted to Shin-Tokyo Hospital for cardiac evaluation and treatment. The functioning transplanted kidney was being maintained with multiple immunodepressants including daily doses of cyclosporin-A 100 mg, mizoribine 100 mg, and prednisone 5 mg. The patient was in New York Heart Association functional class III and Canadian Cardiovascular Society angina class III; the frequency of chest pain had increased prior to admission. She was mildly hypertensive but not diabetic. Blood urea nitrogen was 222 mg•L-1, creatinine 16 mg•L-1, daily urine output 1500 mL, and creatinine clearance 38 mL•min-1. An electrocardiogram demonstrated atrial fibrillation with a heart rate of 66 beats•min-1, and a Holter study showed paroxysmal supraventricular tachycardia associated with symptoms of palpitation and dyspnea. Echocardiography revealed severe mitral regurgitation and a left atrial thrombus. Left ventricular wall motion was diffusely hypokinetic, the calculated ejection fraction was 32%. There was mild pulmonary hypertension (pulmonary artery pressure 39/14 mm Hg, pulmonary wedge pressure 14 mm Hg) on a pressure study of the cardiac chambers. Angiography showed complete obstruction of the proximal right coronary artery (RCA), without significant stenosis on the left circumflex artery or the left anterior descending artery. There were bridging collaterals from the proximal RCA to the middle RCA.
The patient underwent elective open heart surgery. During ascending aortic cannulation for cardiopulmonary bypass (CPB), iatrogenic dissection of the ascending aorta occurred. The femoral artery was quickly exposed and arterial cannulation was completed. After bicaval cannulation, CPB was established and body temperature was cooled to 27°C. The dissection was limited to the proximal ascending aorta, thus an aortic clamp could be applied to the distal ascending aorta, away from the dissection. Cardioplegia (St. Thomas' Hospital solution) was administered retrogradely. Perfusion pressure during CPB was kept above 60 mm Hg. Kosakai's modified maze procedure was performed by making multiple incisions into the right atrium and applying cryoablation in the left atrium. The left atrial appendage was ligated because of the thrombus. The mitral valve was examined, although the leaflets appeared to be intact, there was significant annular enlargement causing mitral regurgitation, probably due to ischemia. Thus, mitral annuloplasty was performed with a Carpentier ring (Baxter Co., Tokyo, Japan) of 28 mm in diameter. Under hypothermic (27°C) circulatory arrest, the ascending aorta was transected at its origin and gelatin-resorcin-formol biological glue was applied into the dissected aortic wall proximally and distally. The adventitia of the dissected aorta was reinforced with Teflon felt. The ascending aorta was replaced with a 26-mm Gelweave graft (Sulzer Vascutek Ltd, Scotland, UK). CPB was reestablished and aortocoronary bypass grafting to the distal RCA was undertaken using saphenous vein. The patient was weaned from CPB uneventfully. Total CPB time was 245 minutes, aortic crossclamp time was 188 minutes, cardiac arrest time 25 minutes, and operative time 480 minutes. Intraoperative urine output was 3200 mL and 10,200 mL of fluid was removed by intraoperative hemodialysis. Total fluid balance was +4300 mL.
In the intensive care unit, hemodynamics were monitored with a Swan-Ganz catheter until urine output and pulmonary artery pressure stabilized. Hemodialysis was performed on postoperative day 1 and 2000 mL of fluid was removed. Dopamine and dobutamine were used to optimize cardiac output. In the early postoperative period, although the patient had achieved an appropriate cardiac output, her urine output was poor and pulmonary pressure was high despite vigorous use of furosemide. Intravenous administration of human atrial natriuretic peptide was started at a dose of 0.05 µg•kg-1•min-1 and her urine output and pulmonary congestion markedly improved. Broad-spectrum intravenous antibiotics were administered for 6 days. Immunodepressants and steroid replacement were started intravenously (daily doses of methylprednisolone 10 mg and cyclosporin-A 40 mg) as soon as the patient was admitted to the intensive care unit; these intravenous medications were switched over to oral medications on postoperative day 2. The patient was extubated on postoperative day 2. Her electrocardiogram showed junctional rhythm and a heart rate of 40 to 50 beats•min-1 immediately after the operation, which converted to sinus rhythm on postoperative day 4. The Swan-Ganz catheter was removed on postoperative day 4. All inotropics were discontinued on postoperative day 5, and she recovered with no neurological deficit, with sinus rhythm, and a serum creatine of 25 mg•L-1.
|
Discussion
|
|---|
Nakhjavan and colleagues5 first reported successful CABG in a renal transplant patient in 1975. Since then, a number of open heart operations for ischemic or valvular disease have been reported in patients with functional renal transplants.6,7 In our patient, the major cause of congestive heart failure was mitral valve regurgitation associated with poor left ventricular function, and mitral valve surgery was mandated. Since the patient was taking immuno-depressants, infection was a major concern. Once endo-carditis occurs in renal transplant patients, it can prove fatal, thus mitral valve repair was chosen instead of valve replacement.7 CABG was performed because of the jeopardized collateral of the RCA. The maze procedure was indicated by the preoperative paroxysmal supraventricular tachycardia that was difficult to control medically. Conversion to sinus rhythm was expected to improve left ventricular function, thus improving the patient's overall cardiac status.
Renal graft dysfunction was another concern. During CPB, the transplanted kidney suffers low perfusion pressure that may have an adverse effect. We maintained the perfusion pressure during CPB above 60 mm Hg and corrected volume overload. Atrial denervation by the maze procedure causes a lack of intrinsic atrial natriuretic peptide, and its replacement contributes to an improvement in urine output.8 Coronary and valvular diseases are not uncommon in renal transplant patients. With appropriate care, open heart surgery, even extensive valvular and coronary artery surgery, is feasible for this particular population.
|
References
|
|---|
-
Batiuk TD, Kurtz SB, Oh JK, Orszulak TA. Coronary artery bypass operation in dialysis patients. Mayo Clin Proc 1991;66:45–53.[Medline]
-
Braum WE, Phillips D, Vidt DG, Novick AC, Nakamoto S, Popowniak KL, et al. Coronary arteriography and coronary artery disease in 99 diabetic and nondiabetic patients on chronic hemodialysis or renal transplantation programs. Transplant Proc 1981;13:128–35.[Medline]
-
Christiansen S, Claus M, Phillipp T, Reidemeister JC. Cardiac surgery in patients with endstage renal failure. Clin Nephrol 1997;48:246–52.[Medline]
-
Rostand SG, Kirk KA, Rutsky EA, Pacifico AD. Results of coronary artery bypass grafting in end-stage renal disease. Am J Kidney 1988;12:266–70.
-
Nakhjavan FK, Kahn D, Rosenbaum J, Ablaza S, Goldberg H. Aorto-coronary vein graft surgery in a cadaver kidney transplant recipient. Arch Intern Med 1975;135:1511–3.[Abstract/Free Full Text]
-
Mitruka SN, Griffith BP, Kormos RL, Hattler BG, Pigula FA, Shapiro R, et al. Cardiac operation in solid-organ transplant recipients. Ann Thorac Surg 1997;64:1270–8.[Abstract/Free Full Text]
-
Dresler C, Uthoff K, Wahlers T, Kleim V, Schäfers J, Oldhafer K, et al. Open heart operations after renal transplantation. Ann Thorac Surg 1997;63:143–6.[Abstract/Free Full Text]
-
Yoshihara F, Nishkimi T, Kosakai Y, Isobe F, Matsuoka H, Takishita S, et al. Atrial natriuretic peptide secretion and body fluid balance after bilateral atrial appendectomy by the maze procedure. J Thorac Cardiovasc Surg 1998;116:213–9.[Abstract/Free Full Text]
TOP
Abstract
Introduction
