Open-heart surgery in patients requiring chronic hemodialysis

The management and outcome of open-heart surgery in 31 patients requiring chronic hemodialysis because of end-stage renal failure are reviewed. The reasons for surgery were coronary artery disease (20 cases), mitral valvulopathy (5, including 3 with tricuspid insufficiency), aortic valvulopathy (5, including 2 with coronary artery disease) and perforation of an aortic aneurysm into the left upper lung lobe. Surgery was elective in all but the last case. Apart from double venous cannulation to avoid potassium overload after cardioplegia, and hemofiltration in the extracorporeal circulation permitting removal of 1,500-2,000 ml fluid during bypass, procedure was routine. Postoperatively fluids were restricted and serum potassium levels were not allowed to exceed the known preoperative maximum. Four patients required catecholamine support for 3-10 hours. Thirty were weaned from the respirator after 8-41 (mean 16) hours. The one perioperative death was due to complications associated with post-bypass administration of protamine. Dialysis was restarted 20-69 (mean 32) hours postoperatively. With appropriate management of fluid balance and potassium, open-heart surgery in dialysis-dependent patients need not carry heightened risk.