Cardiovascular surgical outcomes in patients with the antiphospholipid syndrome--a case-series.

BACKGROUND: Patients with the antiphospholipid syndrome (APLS) have severe involvement of the cardiovascular apparatus and often need surgical interventions to correct these manifestations. Few studies that have looked at the outcomes of cardiothoracic surgeries in APLS patients have reported high rates of perioperative mortality and thromboembolic events. OBJECTIVE: Our goal was to examine the outcomes of adult APLS patients undergoing coronary artery bypass surgery (CABG) and/or valvular surgery. We also wanted to determine whether aggressive anticoagulation therapy could prevent life threatening thromboembolic complications in these patients. METHODS: We retrospectively reviewed medical records of nine patients with primary APLS undergoing cardiothoracic surgery between 1985 and 2005 at our institution. Patient demographics, operative procedures and one-year clinical outcomes were obtained. RESULTS: Forty-five percent of our patients had more than three cardiovascular risk factors other than APLS. There were no mortalities in our case series. However, 89% of our patients developed major complications. Despite aggressive anticoagulation, 37.5% developed thromboembolic events including cerebrovascular accidents, myocardial infarctions and vena caval thrombosis. Other complications included heparin-induced thrombocytopenia, redo of CABG surgery and sepsis. CONCLUSION: Despite aggressive anticoagulation and lack of significant pre-operative co-morbidities, APLS patients undergoing cardiothoracic surgery appear to have high rates of post-operative clinical events.

Outcomes of coronary artery bypass grafting in patients with connective tissue diseases.

BACKGROUND: Coronary artery disease represents a significant cause of morbidity and mortality in patients with connective tissue disease. Few reports exist on the results of surgical management of coronary artery disease in these patients. METHODS: The medical records of patients with connective tissue diseases who underwent coronary artery bypass grafting at our institution between 1995 and 2002 were reviewed for demographic data, perioperative variables, and postoperative complications. The results were compared with data from The Society of Thoracic Surgeons database. RESULTS: Forty-four patients were identified from a total of 5,496 cases during the study period (0.8%). There were 35 patients with rheumatoid arthritis, 8 with systemic lupus erythematosus, and 1 with scleroderma. Patients with connective tissue diseases were more likely to be women and use immunomodulating agents. They also had a higher incidence of Canadian Cardiovascular Society class IV angina, need for inotropic agents, need for intraaortic balloon pulsation, use of blood transfusions, and leg wound infections. The use of steroids or other immunomodulating agents was associated with increased postoperative complications. Mean follow-up was 35 months. The overall survival and freedom from reintervention at 3 years were 89% and 75%, respectively. CONCLUSIONS: Coronary artery bypass grafting is a safe treatment modality in patients with connective tissue diseases, with acceptable early results. Wound complications may be a problem in this patient population. Midterm results are less favorable, and reinterventions are frequently required.

Cardiac operations in patients with hematologic malignancies.

OBJECTIVES: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.