Cardiac valve replacement in patients infected with the human immunodeficiency virus

Infective Endocarditis in Intravenous Drug Abusers

Infective endocarditis (IE) is one of the most severe complications in intravenous drug abusers (IVDA). IE usually involves the tricuspid valve, Staphylococcus aureus is the most common etiologic agent, and it has a relatively good prognosis. Currently, between 40% and 90% of IVDA with IE are HIV infected, and the HIV epidemic has caused a decrease in the incidence of this disease, probably due to changes in drug administration habits undertaken by addicts in order to avoid HIV transmission. This review focuses on progress made over the past few years in some aspects of IE in IVDA. The pathogenesis of tricuspid endocarditis is still unknown more than 60 years after the first series. The most important advance in antibiotic therapy is that noncomplicated S. aureus right-sided endocarditis can be successfully treated with an intravenous 2-week course of nafcillin or cloxacillin plus an aminoglycoside, although probably the aminoglycoside administration could be stopped after the first 3 to 5 days. Surgery in HIV-infected IVDA with IE does not worsen the prognosis. Considering the possibility of reinfection in IVDA, prosthetic material is usually avoided. Tricuspid valvulectomy or valve repair should be considered the technique of choice in IVDA with right-sided IE. Replacement of the tricuspid valve by a cryopreserved mitral homograft is the latest introduction into clinical practice. It provides atrioventricular competence, thereby avoiding late right heart failure. Reinfections can be treated medically with a negligible reoperation rate. Overall mortality for HIV-infected or non-HIV-infected IVDA with IE is similar. However, among HIV-infected IVDA, mortality is significantly higher in those who are most severely immunosuppressed, with CD4(+) cell counts below 200/L or with AIDS criteria.

Coronary artery bypass grafting in patients with human immunodeficiency virus

The role of surgery in the natural history of HIV disease is in evolution. A review was conducted of 2980 CABG operations taking place between January 1992 and January 1996 at St. Vincents Hospital; four of these patients were known to be HIV-positive prior to the operation. Preoperative work-up, operative course, and postoperative events were largely unremarkable. Only 1 of the 4 patients required rehospitalization within 30 days. Follow-up averaged 28 months (range 7-49 months). Three of four patients were in NYHA Class II or better at follow-up. Other reviews of CABG performed on HIV+ patients also indicate that, although CPB can be linked with immune suppression, there is no conclusive evidence of the acceleration of HIV into AIDS associated with CPB. In conclusion, due to the lack of controlled trials and large patient reviews, no firm recommendations about the effect of CPB on immunocompromized patients can be generated.

Issues in surgical treatment of endocarditis including intraoperative and postoperative management

Patients with infective endocarditis who require surgical intervention can be divided into four separate groups, in order of incidence: (1) patients with underlying acquired or congenital cardiac lesions or valvar abnormalities, (2) patients with preexisting prosthetic valves, (3) patients with nosocomial infections who are immunosuppressed, and (4) older patients with infection risk or patients with indwelling deep venous catheters. The surgical management for these individual groups and for specific valve lesions is discussed, along with illustrative case studies.

Cardiopulmonary bypass in HIV-positive patients

To prove the hypothesis that cardiopulmonary bypass may accelerate the development of acquired immunodeficiency syndrome (AIDS) in the human immunodeficiency virus carrier, the clinical course of 40 patients positive for human immunodeficiency virus who underwent cardiac operations between 1986 and 1992 was analyzed, especially in regard to the progression to AIDS. Mean age was 30 years (range, 19 to 61 years). Thirty-four patients (85%) were intravenous drug abusers; in 4 (10%) transmission of infection was sexual, and in 2 (5%) it was through a contaminated blood transfusion. Valve procedures were performed in 38 patients (95%), mostly for endocarditis in drug addicts. Hospital mortality was 20% (8 patients). The 32 survivors have been followed up a mean of 21 months (range, 4 months to 6 years). Four patients (12.5%) experienced progression to AIDS during the follow-up period. Actuarial progression to AIDS is 5% (+/- 5%) at 1 year, 20% (+/- 10%) at 2 years, and 40% (+/- 19%) at 5 years. There have been 8 late deaths (5 due to recurrent endocarditis, 2 due to AIDS, and 1 due to overdose). Actuarial survival is 79% (+/- 8%) at 1 year, 60% (+/- 11%) at 2 years, and 48% (+/- 14%) at 5 years. The results indicate that progression to AIDS in the patient positive for human immunodeficiency virus is not accelerated by the use of cardiopulmonary bypass. The poor prognosis in these patients is mainly related to the particular pathological conditions that often affect the drug addict population.