Cardiac Surgery in Systemic Lupus Erythematosus Patients: Clinical Characteristics and Outcomes

Lauro Quintanilla-González¹, Javier Tejeda-Maldonado², Jaime Galindo-Uribe³ and Andrea Hinojosa-Azaola⁴, ¹Immunology & Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, ²Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, ³Cardiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, ⁴Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

Meeting: 2016 ACR/ARHP Annual Meeting

Date of first publication: September 28, 2016

Keywords: Cardiovascular disease, Perioperative management, surgery and systemic lupus erythematosus (SLE)

Session Information

Date: Monday, November 14, 2016

Title: Systemic Lupus Erythematosus – Clinical Aspects and Treatment - Poster II: Damage Accrual and Quality of Life

Session Type: ACR Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: To study the clinical characteristics and outcomes of Systemic Lupus Erythematosus (SLE) patients that underwent cardiac surgery.

Methods: Retrospective analysis of 30 SLE patients (ACR classification criteria), who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical, serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. Statistics: Differences between groups were evaluated with the Student t test or Mann-Whitney U test (continuous variables); chi-square or FisherÕs exact test (categorical variables). Odds ratios (OR) and 95% confidence intervals are presented.

Results: Disease duration at surgery was 2 years. Valve replacement was the most frequent procedure in 16 (53%), followed by pericardial window in 11 (37%). Indications for pericardial window were cardiac tamponade and recurrent pericarditis. Tables 1 and 2 summarize characteristics of SLE at cardiac surgery. At least one postoperative complication was present in 63% (mainly infections). An aortic cross-clamp time > 76 minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=0.03). Main valvular histopathological findings in the patients that underwent valve replacement were: myxoid degeneration (n=5), fibrosis (n=5), Libman-Sacks endocarditis (n=3), endocarditis (n=3). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Patients with active disease were associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=0.007); lymphopenia < 1200 (OR 10.1, 95% CI 1.05-97, p=0.04); age < 30 years (OR 7.7, 95% CI 1.2-46.3, p=0.02), NYHA class III (OR 7.0, 95% CI 1.1-42, p=0.03). Patients with postoperative infections were associated with length of hospital stay > 2 weeks (OR 54.9, 95% CI 5.0-602.1, p=0.001); days in ICU > 10 (OR 20, 95% CI 1.6-171.7, p=0.01); duration of mechanical ventilation > 5 days (OR 16.9, 95% CI 1.6-171.7, p=0.01), pulmonary artery systolic pressure > 50 mmHg (OR 7.8, 95% CI 1.4-41.2, p=0.01).

Conclusion: Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors. Table 1

Variable
Age―years	27 (18-59)
Disease duration―months	48 (0-241)
Prednisone―n (%)	23 (77)
Current dose of prednisone―mg	6.2 (0-240)
Azathioprine―n (%)	13 (43)
Current dose of azathioprine―mg	0 (0-200)
Mycophenolate mofetil―n (%)	2 (7)
Current dose of mycophenolate mofetil―mg	0 (0-2500)
Antimalarials―n (%)	8 (27)
Aspirin―n (%)	3 (10)
Oral anticoagulants―n (%)	4 (13)
SLEDAI-2K score	2 (0-27)
SLICC/ACR Damage Index	2 (0-6)
Anti-dsDNA	22.2 (1.7-2743)
Anti-dsDNA +―n +/n tested (%)	20/23 (87)
Low C3―n (%)	12 (43)
Low C4―n (%)	13 (46)

Table 2

Variable	N (%)
Echocardiographic findings
LVEF―%^a	61 (12)
Pulmonary artery systolic pressure―mmHg^a	42 (23)
Right ventricular dysfunction―n (%)	8 (27)
Valvular vegetations―n (%)	6 (21)
Affected valve―n (%) None Aortic Mitral Aortic+Mitral Aortic+Pulmonary Mitral+Pulmonary Mitral+Tricuspid 4 valves	11 (37) 6 (20) 4 (13) 1 (3) 1 (3) 1 (3) 4 (13) 1 (3)
Valvular insufficiency―n (%) Mild Moderate Severe	7 (24) 8 (28) 8 (28)
Valvular stenosis―n (%) Mild Moderate Severe	1 (3) 2 (7) 6 (21)
NYHA class―n (%) I II III IV	7 (23) 9 (30) 9 (30) 5 (17)
EuroSCORE II―%	2 (0.3-11.2)
Laboratory parameters Hemoglobin―g/dl Leukocytes x10³/mm³ Neutrophils x10³/mm³ Lymphocytes x10³/mm³ Platelets―K/ul Serum creatinine―mg/dl Albumin―g/dl ESR―mm/h CRP―mg/dl	10 (6.6-15.2) 6.6 (2.2-24.4) 4.8 (1.8-21.5) 0.7 (0.1-2.8) 215 (13-657) 0.9 (0.3-8.0) 2.8 (1.6-4.4) 24 (2-67) 2.8 (0.4-6.5)
Type of surgery―n (%) Valve replacement Pericardial window Revascularization Pericardiectomy Auricular thrombectomy	16 (53) 11 (37) 1 (3) 1 (3) 1 (3)
Emergency surgery―n (%)	2 (7)
Urgent surgery―n (%)	18 (60)
Elective surgery―n (%)	10 (33)
Surgical time―hours	3 (1-7)
Extracorporeal circulation time―minutes	97.5 (45-265)
Aortic cross-clamp time―minutes	76 (30-195)
Blood transfusion―units	2 (0-4)
Bleeding―ml	450 (10-2400)
Type of prosthetic heart valve―n (%) Biological Mechanical	1 (6) 15 (94)
Days in ICU	4 (0-96)
Mechanical ventilation―days	1 (0-96)
Hospital stay―days	13 (0-96)

Disclosure: L. Quintanilla-González, None; J. Tejeda-Maldonado, None; J. Galindo-Uribe, None; A. Hinojosa-Azaola, None.

To cite this abstract in AMA style:

Quintanilla-González L, Tejeda-Maldonado J, Galindo-Uribe J, Hinojosa-Azaola A. Cardiac Surgery in Systemic Lupus Erythematosus Patients: Clinical Characteristics and Outcomes [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/cardiac-surgery-in-systemic-lupus-erythematosus-patients-clinical-characteristics-and-outcomes/. Accessed .

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