Cardiac Surgery in Patients with Major Lower Extremity Amputation: A Single Institution Experience1

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Background

Cardiac surgery patients with lower-extremity amputations pose a challenge in terms of medical comorbidities and functional recovery.

Methods

A retrospective review of all patients (n = 10) with preexisting below-knee amputation (BKA) or more proximal amputation level who underwent cardiac surgery between April 1998 and April 2008. Data were analyzed to evaluate outcomes.

Results

The median age was 59 y (range, 51–75 y). One patient had bilateral above-knee amputation (AKA), and 9 had BKAs (two bilateral). Comorbidities included diabetes (n = 5), peripheral vascular disease (n = 7), cerebrovascular disease (n = 2), hypertension (n = 9), chronic renal insufficiency (n = 2), pulmonary hypertension (n = 1), and pulmonary fibrosis (n = 1). Nine patients underwent coronary artery bypass grafting and one patient underwent aortic valve replacement. There were no operative deaths. The median length of hospital stay (to home discharge) was 12.5 d (range, 5–562 d). Eight patients were transferred to a rehabilitation unit or a chronic care facility before being discharged to home. At follow-up (median, 1.5 y; range, 0.4–3.8 y), all but one patient were alive and had returned to their preoperative ambulatory status.

Conclusions

In our experience, patients with lower-extremity amputations require prolonged hospitalization after cardiac surgery but can expect good mid-term outcomes and functional recovery.

Introduction

Patients in need of lower extremity amputations represent a high-risk population with a markedly diminished long-term survival. A recent study by the Department of Veterans Affairs reported a 28% and 20% survival at 7.5 y for patients with a below knee amputation (BKA) and above knee amputation (AKA), respectively [1]. As expected, cardiovascular disease is common in amputees with underlying peripheral vascular disease, but there is also an increased cardiovascular mortality rate in patients with traumatic limb amputations [2].

Patients with lower extremity amputations, who are referred for cardiac surgery, pose a challenge in terms of associated medical comorbidities and functional recovery after surgery. Patients with lower extremity amputation rely heavily on their upper girdle for transfer and ambulatory activities. The sternal precautions, including weight lifting restrictions instituted after cardiac surgery, are likely to delay or interfere with cardiac rehabilitation, which is vital for optimal functional recovery after cardiac surgery 3, 4. Postoperative edema of the amputation stump and concerns about friction against vein harvest incisions can delay the application of the limb prosthesis, creating further difficulties. Little is known about the specifics of cardiac operative management of amputees and their postoperative outlook. We report our experience with BKA and AKA patients who underwent cardiac surgery with special emphasis on the unique aspects of surgical care, outcomes, and functional recovery.

Section snippets

Material and Methods

With Institutional Review Board approval and with waiver of individual consent granted, a retrospective review was performed of all patients with preexisting major lower extremity amputation who underwent cardiac surgery at the Michael E. DeBakey Veterans Affairs medical center (MEDVAMC) between April 1998 and April 2008. A major amputation was defined as BKA or an amputation at a more proximal level. Patients with lesser amputations including toe, foot, and Syme's amputations were excluded.

Patient Profile

Between April 1998 and April 2008, 10 patients with major lower extremity amputations underwent cardiac surgery. All were men with a median age of 59 y (range, 51–75 y).

Signs SS Comorbidities included diabetes (n = 5), peripheral vascular disease (n = 7), cerebrovascular disease (n = 2), hypertension (n = 9), hyperlipidemia (n = 7), chronic renal insufficiency/dialysis (n = 2), pulmonary hypertension (n = 1), and pulmonary fibrosis (n = 1); seven patients were smokers (Table 1). All but one patient (patient

Discussion

The Veterans Affairs Health Administration performs about 10% of amputations in the U.S. male population [5]. Amputation of the lower extremity is regarded as an ominous event portending poor survival. Cardiovascular disease is a major risk factor that impacts survival in patients with lower extremity amputations [1]. Mayfield et al. reported less than 50% 4-y survival in veterans with amputation and cardiovascular disease. More strikingly, almost half of the subset of patients with congestive

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Accepted for presentation at the Fourth annual Academic Surgical Congress, February 3-6, 2009, Fort Myers, Florida.

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