Cardiac Surgery in Patients with Systemic Lupus Erythematosus: A Medical Center's Experience in Taiwan

Abstract

Objective: To analyze the clinical outcomes of systemic lupus erythematosus (SLE) patients who underwent cardiac surgery and to investigate the appropriateness of cardiac valve surgery in SLE patients with lupus nephropathy-related chronic kidney disease (CKD) and valvular heart disease (VHD). Methods: It was a retrospective review to evaluate SLE patients who underwent cardiac surgery because of VHD or coronary artery disease (CAD) between January 2000 and January 2010. Clinical outcome measurements included in-hospital mortality rate and postoperative complications such as vascular events and infections. The outcomes of SLE patients with VHD who did not undergo cardiac valve surgery were analyzed simultaneously. Results: Seven patients who underwent cardiac surgery were identified: five women and two men. The median duration of SLE from diagnosis to the surgery was 7.3 years (range 1-20 years). The median age was 58 years (range 28-72 years). Five patients received cardiac valve surgery; all five demonstrated stage III, IV, or V CKD and New York Heart Association class III or IV heart failure. Three patients underwent coronary artery bypass grafting (CABG) for double-vessel CAD, one of whom received concurrent mitral annuloplasty. Twenty-six patients presenting with VHD who did not undergo cardiac valve surgery were also evaluated as control cases. Two of the seven SLE patients who underwent cardiac surgery died, giving a mortality rate of 28.6%. Two of the five SLE patients who underwent cardiac valve surgery died while hospitalized, giving a mortality rate of 40%. One of the three patients who underwent CABG who also received cardiac valve surgery at the same time died. Two of the SLE patients with VHD who did not have surgery died (p=0.02 compared with SLE patients with VHD who received an operation). Both the one-year and five-year survival rates were 92.3% among SLE patients with VHD without surgery and 60% in those who underwent cardiac valve surgery. Conclusions: Cardiac surgery is performed rarely in SLE patients. The poor outcomes of cardiac surgery probably reflect the older age, poor heart function, severe renal insufficiency, and more frequent hemolytic anemia. SLE patients often demonstrate lupus nephropathy-related CKD concomitantly with VHD with symptomatic heart failure, both of which share similar clinical manifestations, including fluid overloading and limited daily performance status. Before cardiac surgery, we should optimize medical treatment and cardiac rehabilitation for SLE patients with VHD and symptomatic heart failure.