Coronary artery bypass grafting in patients who require long-term dialysis.

BACKGROUND: Should coronary artery bypass grafting (CABG) be performed in patients on long-term dialysis? This subject has been debated for several years. We retrospectively reviewed the charts of all patients who had CABG from August 1989 to October 1997.
METHODS: We identified 70 patients who were on long-term dialysis and had CABG during that time period. Patients were evaluated by chart review and telephone survey. Forty-nine patients (70%) had unstable angina and 37 patients (52%) had triple vessel disease. Patient risk factors included 60 patients with hypertension (85%), 40 patients with diabetes mellitus (57%), 35 patients who had congestive heart failure (50%), 35 patients who had a previous myocardial infarction (50%), and 31 smokers (44%). Operative procedures included 49 patients who had CABG only and 21 patients who had concomitant CABG with valve replacement or repair. During the postoperative period, complications developed in 50% of patients.
RESULTS: Review of these complications showed that 25% of patients required prolonged mechanical ventilation, and 10% of patients had septicemia. Operative mortality was high, with 10 patient deaths (14.3%) within 30 days of the procedure. Six (60%) of these deaths occurred in patients who had CABG and valve repair or replacement. Long-term follow up at 50.3 months showed no improvement in survival in patients who had CABG compared with the known mortality rate of 22% per year in dialysis patients regardless of comorbid conditions. Quality of life subjectively improved in only 41% of patients in follow-up telephone survey.
CONCLUSIONS: Patients requiring long-term dialysis with coexistent severe cardiac disease should be thoroughly evaluated preoperatively. One must weigh the high morbidity and mortality risk against the limited long-term resolution of angina and ultimate survival.