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Coronary artery bypass grafting in patients who require long-term dialysis
L Khaitan1, F P Sutter, S M Goldman
1Main Line Cardiothoracic Surgeons, Lankenau Hospital, Jefferson Health System, Wynnewood, Pennsylvania 19066, USA.
Insights
Coronary artery bypass grafting (CABG) in dialysis patients carries high risks and offers limited survival benefits. Thorough preoperative evaluation is crucial to weigh risks against potential improvements in angina and survival.
Area of Science:
- Cardiology
- Nephrology
- Cardiac Surgery
Background:
- Debate exists regarding the efficacy of coronary artery bypass grafting (CABG) for patients on long-term dialysis.
- This study retrospectively analyzes CABG outcomes in dialysis patients between 1989 and 1997.
Purpose of the Study:
- To evaluate the risks, complications, and long-term outcomes of CABG in patients requiring long-term dialysis.
- To inform preoperative decision-making for this high-risk patient group.
Main Methods:
- Retrospective chart review and telephone surveys of 70 patients on long-term dialysis who underwent CABG.
- Analysis of patient demographics, risk factors, operative procedures, complications, and long-term survival.
Main Results:
- High complication rates (50%), including prolonged mechanical ventilation (25%) and septicemia (10%).
- Operative mortality was 14.3%, with 60% of deaths in patients undergoing concomitant valve procedures.
- No significant long-term survival benefit was observed compared to the expected mortality rate for dialysis patients.
Conclusions:
- CABG in long-term dialysis patients is associated with substantial morbidity and mortality.
- Careful preoperative assessment is essential to balance surgical risks with potential benefits for angina relief and survival.
Background:
Should coronary artery bypass grafting (CABG) be performed in patients on long-term dialysis? This subject has been debated for several years. We retrospectively reviewed the charts of all patients who had CABG from August 1989 to October 1997.
Methods:
We identified 70 patients who were on long-term dialysis and had CABG during that time period. Patients were evaluated by chart review and telephone survey. Forty-nine patients (70%) had unstable angina and 37 patients (52%) had triple vessel disease. Patient risk factors included 60 patients with hypertension (85%), 40 patients with diabetes mellitus (57%), 35 patients who had congestive heart failure (50%), 35 patients who had a previous myocardial infarction (50%), and 31 smokers (44%). Operative procedures included 49 patients who had CABG only and 21 patients who had concomitant CABG with valve replacement or repair. During the postoperative period, complications developed in 50% of patients.
Results:
Review of these complications showed that 25% of patients required prolonged mechanical ventilation, and 10% of patients had septicemia. Operative mortality was high, with 10 patient deaths (14.3%) within 30 days of the procedure. Six (60%) of these deaths occurred in patients who had CABG and valve repair or replacement. Long-term follow up at 50.3 months showed no improvement in survival in patients who had CABG compared with the known mortality rate of 22% per year in dialysis patients regardless of comorbid conditions. Quality of life subjectively improved in only 41% of patients in follow-up telephone survey.
Conclusions:
Patients requiring long-term dialysis with coexistent severe cardiac disease should be thoroughly evaluated preoperatively. One must weigh the high morbidity and mortality risk against the limited long-term resolution of angina and ultimate survival.