CARDIOPULMONARY BYPASS PROCEDURES IN DIALYSIS PATIENTS

To determine the operative outcome of chronic renal failure patients, we retrospectively reviewed twenty-five consecutive adult patients with chronic renal failure dependent on maintenance hemodialysis (21) or peritoneal dialysis (3), who underwent cardiopulmonary bypass procedures over a five-year period in our institution. The operations included isolated coronary artery bypass grafting in 16 patients; aortic valve replacement in 3; aortic valve replacement plus mitral valve replacement in 1; aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting in 2; aortic valve replacement and coronary artery bypass grafting in 1, mitral valve replacement and coronary artery bypass grafting in 1, and repair of a thoracoabdominal aortic aneurysm in 1 patient. Fourteen operations were elective, and 11 were urgent or emergent. The number of patients with good (>0.50), fair (0.30 to 0.50), and poor (<0.30) left ventricular ejection fractions were 13, 9, and 3, respectively. There were 0, 7, 7, and 11 patients in New York Heart Association functional classification I, II, III, and IV, respectively. All patients were dialyzed within 24 hours before operation. All but 3 patients were managed by immediate postoperative peritoneal dialysis via a Technoff catheter placed intraoperatively (18 patients) or via a preexisting Technoff catheter (4 patients). This was then switched to hemodialysis when clinical conditions stabilized. Univariate analysis of 22 preoperative and intraoperative variables, followed by a multivariate analysis with a stepwise logistic regression model, was performed using the 30-day or in-hospital operative mortality as the dependent variable. The urgency of the operation and New York Heart Association class IV were found to be independent variables associated with increased operative mortality. There were no operative deaths among the 14 patients having elective operation; 4 of the 11 patients having nonelective operation died postoperatively, constituting a 36% operative mortality for this subgroup. All operative deaths occurred in the patients in preoperative New York Heart Association class IV (4/11 or 36%). This study demonstrated that elective cardiopulmonary bypass operations can be performed in chronic renal failure patients with excellent operative outcome, when done with careful perioperative management. Patients having nonelective operations and patients in the most advanced stage of their cardiac diseases had substantial operative mortalities in this series. The overall operative mortality of the 296 cases reported in the English-language literature thus far is 9%.