Case Report AIDS and Heart Disease: Is Cardiac Surgery Justified? Manish Agaskar, MCh, 1 Nitin Ghorpade, MCh, 1 Eugene Athan, FRACP 2 and Morteza Mohajeri, FRACS 1 Department of 1 Cardiothoracic Surgery and 2 Infectious Diseases, The Geelong Hospital, Barwon Health, Geelong, Victoria, Australia A compromised immune system, limited survival and increased risk to the anaesthetic and surgical team of acquiring HIV infection have been the major concerns in offering cardiac surgery to patients with AIDS. The current report presents a patient with AIDS who underwent successful, uncomplicated coronary artery surgery. He remains free of ischaemic and any infective symptoms 12 months postoperatively. (Heart, Lung and Circulation 2003; 12: 193–195) Key words: AIDS, coronary artery bypass grafting, coronary artery disease, survival. efore the era of highly active antiretroviral therapy (HAART), the long-term survival of HIV infected patients was unusual and an aggressive approach to treating coronary artery disease was not justified. 1 Cardiopulmonary bypass was also considered to be potentially damaging in this immunocompromised group. Several systems for the classification of HIV infec- tion and disease have been developed. 2 Both the CD4 lymphocyte count, as a marker of cellular immunocom- petence, and more recently the HIV-RNA viral load, correlate closely with disease progression and prog- nosis. 3,4 Since the advent of HAART in the mid- to late- 1990s there has been a dramatic improvement in the long-term survival of HIV infected patients, as well as those who have progressed to AIDS. 5,6 Unfortunately, along with improved survival, many of the newer antiretroviral agents, in particular the protease inhibitors, have also increasingly been associated with lipo- dystrophy, hyperlipidaemia and premature coronary artery disease. 7 We propose that surgical revascularisa- tion for coronary artery disease in this patient group deserves reconsideration. Case Report We report the case of a 60-year-old man with AIDS who underwent successful coronary artery bypass surgery. He was first diagnosed with HIV infection 7 years earlier during investigations for recurrent bacteremia. His main risk factor was having unprotected sex with men. He developed several AIDS defining opportunistic infec- tions during this period, including perianal herpes sim- plex, Campylobacter bacteremia, and a left frontal lobe lesion thought to be due to Cryptococcus neoformans. 2 At this stage his CD4 lymphocyte count was 40/mm 3 . Following the commencement of combination anti- retroviral therapy including a protease inhibitor, there was a significant response with his CD4 count increasing to 572/mm 3 and the HIV-RNA (viral load) was meas- ured at 67 copies/mL. He also had a 3-year history of chronic stable angina. He was admitted with a non-Q wave myocardial infarc- tion and continued to have frequent episodes of angina. His risk factors for ischaemic heart disease were hyper- cholesterolaemia and borderline hypertension. Coronary angiography demonstrated 70% stenosis of the left anterior descending (LAD) artery, significant stenosis of origin at the first diagonal branch of the LAD. There was 80% stenosis in circumflex artery and the obtuse marginal (OM) branch was small in size. The right coronary artery (RCA) was occluded and its distal branch was filling through collateral circulation from the left system. Left ventricular function was preserved. Myocardial revascularisation was performed using conventional methods of cardiopulmonary bypass; hypo- thermia at 32°C, cardiac arrest and myocardial protection using cold blood cardioplegia. The left internal Correspondence: Morteza Mohajeri, Department of Cardiothoracic Surgery, The Geelong Hospital, PO Box 281, Geelong, Victoria 3220, Australia. Email: morteza@barwonhealth.org.au B