An experience with cardiopulmonary bypass in HIV-infected patients

Having noted the good clinical status of some HIV patients who were referred for but refused surgery, we undertook surgery with the aim of determining outcome, risk-to-benefit ratio and, if possible, the effect of surgery with cardiopulmonary bypass (CPB) on the progression of their HIV disease. Antiretroviral drugs (ARVD) were not available to these patients. The records of 49 patients, 17 males and 32 females, aged between 17 and 67 years, undergoing surgery with cardiopulmonary bypass over a nine-year period, were reviewed. Forty-eight of these underwent cardiac surgery and one aortic dissection repair. Four HIV-infected patients underwent surgery with good early outcome. Thereafter an absolute CD4 cell count greater than 400/microl (normal 550*1 955/microl) and the absence of the stigmata of AIDS in patients fulfilling the normal criteria for surgery allowed cardiac surgery using CPB. Fifty operations were performed. Three patients with CD4 counts of 37, 868 and 1 245/microl died early, giving a 30-day mortality of 6% for 50 procedures. Six patients with active infective endocarditis (IE) underwent emergency surgery. Three of these, one with a pre- and two with only post-operative counts all below 250/microl, died within three months. Sixteen complications occurred in the remaining 46 patients (34.7%). Pre-operative CD4 cell counts taken in 42 patients averaged 685/microl. Pre- and post-operative counts known in eight showed variations, as did repeated counts in those awaiting surgery. Forty-one patients left hospital in the New York Heart Association (NYHA) class I, five in class II and one in class III. Prior to surgery, the majority (38) were in class III and seven were in class IV. Follow up ranging from two to 70 months averaged 23.1 months. Eight late deaths occurred, three related to AIDS. We found surgery to be worthwhile in selected HIV-infected patients. Early outcome paralleled that in the uninfected, giving a low risk-to-benefit ratio. Emergency surgery in those with active infective endocarditis and marked immune compromise met with high mortality. It is essential in our population to test and stage all patients for HIV. We could not show that CPB accelerated progression to AIDS. This experience and the present availability of ARVDs would enable us to review our selection criteria for surgery.