Heart surgery just as successful in HIV-positive people, New York hospital reports

An increasing number of HIV-positive people are growing old enough to need heart surgery and can expect it to be very effective, according to results from the first large study done in the highly active antiretroviral therapy (HAART) era. Researchers from Mount Sinai Medical Centre in New York have looked back through the medical records of 4,952 people who underwent open-heart surgery there between 1998 and 2004.

They found 25 individuals who had been infected with HIV, 13 of whom were taking antiretroviral treatment at the time of surgery.

According to the US Centers for Disease Control and Prevention (CDC) classification system 40% of the patients were category one with CD4 counts of above 500 cells/mm³ and 44% were category two with CD4 counts of between 200 and 499 cells/mm³. Only four patients, 16% of the total, were in category three with CD4 counts of less than 200 cells/mm³.

Just one patient died in hospital while the remaining 24 were followed for an average of just under four years. In that time three patients died, 12.5% of the total.

The researchers compared these figures with a similar group of HIV-negative open-heart surgery patients from the same time and found no significant difference between the two groups.

Two of the three patients who died during follow-up had category two or category three CD4 counts at the time of surgery.

The most common reason surgery was needed (in 14 patients or 56%) was endocarditis - an inflammation of the inside lining of the heart chambers, heart muscles and heart valves (endocardium). Anyone can develop endocarditis, but people with underlying heart valve disease or certain congenital heart diseases are most at risk.

In seven patients (28%) surgery was needed for severe coronary heart disease caused by a build up of fatty substances in the arteries.

The researchers say these are important results as studies looking at outcomes from surgery in HIV-positive people are rare and these are the best results yet.

This is probably due to a number of factors they say. The treatment of HIV infection and AIDS has improved dramatically as has the effectiveness of surgery itself.

But although most people with HIV who need cardiac surgery have endocarditis that number seems to be dropping with more having coronary heart disease which has a better outcome.

However it is not all good news, they say. The overall survival rates are excellent but complications after surgery, including bleeding, respiratory problems, infections and kidney failure, are still high in HIV-positive people.

These complications only occurred in HIV-positive people with risk factors - such as lower CD4 cell counts, previous lung infection, co-infection with hepatitis C, liver cirrhosis and existing kidney disease

Overall the picture is optimistic they conclude. An increasing number of people with HIV are being referred for open-heart surgery. This is partly due to the fact that their life expectancy is increasing, consequently leaving them vulnerable to heart disease as they grow older in the same way that non-infected people are.

These findings mean surgeons should not hesitate to carry out major cardiac surgery, when needed, in patients with AIDS or HIV infection.

But they warn there is also evidence that the new multidrug combinations might be contributing to the development of premature coronary heart disease.

Last year American and Canadian researchers reported that the abnormal lipid levels in the blood (termed dyslipidemia) associated with HAART in some HIV-positive individuals may increase the risk of coronary disease by as much as 50% (Grover).

The authors of this latest study emphasise that HIV-infected people taking HAART need close monitoring of their cardiac health.