Cardiac Surgery Poses No Undue Risk For HIV-Positive Patients

Surgery should not be withheld due to their HIV status alone

Performing cardiac surgery on HIV-positive patients is surprisingly safe, say Cleveland Clinic surgeons. A retrospective study of 9,771 patients with HIV who underwent cardiac surgery nationwide found no increased hospital mortality, compared with patients who were HIV-negative. Moreover, the need for blood transfusion was only minimally increased, and the rate of stroke was actually lower than in non-HIV patients.

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“This was surprising, especially because in the general population, HIV patients experience more strokes overall than non-HIV patients. This finding may be related to the fact that HIV patients experience less postoperative atrial fibrillation, which is itself a cause of stroke in patients undergoing heart surgery,” says Cleveland Clinic cardiothoracic surgeon Edward Soltesz, MD, MPH, who co-authored the study with cardiothoracic fellow Michael Robich, MD.

HIV and the heart

The Cleveland Clinic study was prompted by the number of HIV patients sent to Dr. Soltesz for surgery after being declined elsewhere. Although his outcomes were very good, he was unable to ascertain how they compared nationally. “There was no good, large, nationwide analysis of outcomes: only small series from various centers,” he says.

He turned to the Nationwide Inpatient Sample, a large database that captures a sampling of all hospital discharges throughout the country, and chose patients who underwent CABG, valve, aortic or other cardiovascular surgery between 1998 and 2009. This produced 5,621,817 patients, of whom 9,771 were HIV-positive. The percentage of HIV patients who underwent cardiovascular surgery increased significantly during the study period, from 0.09 percent in 1998 to 0.23 percent in 2009. HIV-positive patients were more likely to be male, black, younger than 55, and have Medicaid.

HIV-positive patients were more likely to undergo valve surgery and less likely to undergo CABG than non-HIV patients—a seeming contradiction. “Other studies have shown that HIV patients have accelerated rates coronary artery disease and present with CAD at a much earlier age than non-HIV patients. The low rates of CABG may be due to treatment bias: HIV patients may be receiving medical therapy or stents for coronary disease more often than surgery since they are thought to be high-risk surgical candidates,” says Dr. Soltesz.

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Fears unfounded

Among propensity-matched pairs, patients with HIV were at no increased risk for inpatient mortality.  Additionally, they were less likely to suffer a post-operative stroke. However, they did require more blood transfusions than non-HIV patients. “This is likely related to the fact that HIV-positive patients are more anemic as a group,” says Dr. Soltesz.

Rates of pneumonia and renal complications were similar between the groups. Additionally,  HIV-positive patients were not found to have a higher risk of infection than non-HIV patients. Dr. Soltesz credits advances in both cardiac surgery and anti-retro viral therapy for the low-rate of postoperative infectious complications. “These patients may not be as immune-compromised as we thought,” he says.

On average, HIV-positive patients stayed in the hospital one day longer than HIV-negative patients. The total cost was similar between the groups.

Factors that predicted in-hospital death in HIV-positive patients included metastatic cancer, coagulopathy, renal failure, and certain surgical procedures (aortic operations and pericardial drainage procedures).

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Although this study fills a knowledge gap, Dr. Soltesz plans to conduct a more detailed clinical analysis of HIV patients undergoing cardiac surgery to more clearly link the stage of HIV, duration of HIV, and state of immunocompetency of the patient (based on viral load) with clinical outcomes. These data points were not available in the Nationwide Inpatient Sample database and will require detailed patient data.

“Being the largest heart center in the US, we will certainly look into this in order to provide the best care to the HIV-positive patient population ,” he says.