全身性紅斑性狼瘡病患接受心臟手術分析

Cardiac surgery in patients with systemic lupus erythematosus: a medical center's experience in Taiwan

目的：分析全身性紅斑性狼瘡病患接受心臟手術之預後。方法：回溯分析自2000年1月至2010年1月某醫學中心全身性紅斑性狼瘡病患因瓣膜性心臟病或冠狀動脈疾病接受心臟手術者之住院內死亡率及術後併發症。結果：7位全身性紅斑性狼瘡病患接受心臟手術，包括5位女性及2位男性。5位病患接受心臟瓣膜手術，3位病患接受冠狀動脈繞道手術。2位全身性紅斑性狼瘡病患接受心臟手術者死亡，住院內死亡率為28.6%，2位死亡患者皆接受心臟瓣膜手術，故全身性紅斑性狼瘡病患接受心臟瓣膜手術者住院內死亡率為40%，術後1年存活率及5年存活率皆為60%。同時分析另外26位全身性紅斑性狼瘡病患合併瓣膜性心臟病卻未接受手術者作為對照組。全身性紅斑性狼瘡病患合併瓣膜性心臟病卻未接受手術者計有2位死亡，死亡率為7.7%（p=0.02），1年存活率及5年存活率皆為92.3%。結論：全身性紅斑性狼瘡病患接受心臟手術者為少數。全身性紅斑性狼瘡病患可因年紀、腎功能不佳、心臟衰竭、及溶血性貧血等影響心臟手術預後。嚴重狼瘡腎炎引起之腎衰竭及狼瘡併發之瓣膜性心臟病併嚴重心臟衰竭皆會導致類似臨床症狀如全身水腫及端坐呼吸等，全身性紅斑性狼瘡病患手術前應先接受最佳的內科治療諸如減低心臟後負擔及心臟復健等。

Objective: To analyze the clinical outcomes of systemic lupus erythematosus (SLE) patients who underwent cardiac surgery and to investigate the appropriateness of cardiac valve surgery in SLE patients with lupus nephropathy-related chronic kidney disease (CKD) and valvular heart disease (VHD). Methods: It was a retrospective review to evaluate SLE patients who underwent cardiac surgery because of VHD or coronary artery disease (CAD) between January 2000 and January 2010. Clinical outcome measurements included inhospital mortality rate and postoperative complications such as vascular events and infections. The outcomes of SLE patients with VHD who did not undergo cardiac valve surgery were analyzed simultaneously. Results: Seven patients who underwent cardiac surgery were identified: five women and two men. The median duration of SLE from diagnosis to the surgery was 7.3 years (range 1-20 years). The median age was 58 years (range 28-72 years). Five patients received cardiac valve surgery; all fi ve demonstrated stage III, IV, or V CKD and New York Heart Association class III or IV heart failure. Three patients underwent coronary artery bypass grafting (CABG) for double-vessel CAD, one of whom received concurrent mitral annuloplasty. Twenty-six patients presenting with VHD who did not undergo cardiac valve surgery were also evaluated as control cases. Two of the seven SLE patients who underwent cardiac surgery died, giving a mortality rate of 28.6%. Two of the fi ve SLE patients who underwent cardiac valve surgery died while hospitalized, giving a mortality rate of 40%. One of the three patients who underwent CABG who also received cardiac valve surgery at the same time died. Two of the SLE patients with VHD who did not have surgery died (p=0.02 compared with SLE patients with VHD who received an operation). Both the one-year and fi ve-year survival rates were 92.3% among SLE patients with VHD without surgery and 60% in those who underwent cardiac valve surgery. Conclusions: Cardiac surgery is performed rarely in SLE patients. The poor outcomes of cardiac surgery probably reflect the older age, poor heart function, severe renal insufficiency, and more frequent hemolytic anemia. SLE patients often demonstrate lupus nephropathy-related CKD concomitantly with VHD with symptomatic heart failure, both of which share similar clinical manifestations, including fl uid overloading and limited daily performance status. Before cardiac surgery, we should optimize medical treatment and cardiac rehabilitation for SLE patients with VHD and symptomatic heart failure.