Twenty years after the first antibody test for the human immunodeficiency virus (HIV), highly active antiretroviral therapy (HAART) became available in Western coun­tries.

Although cardiac surgery in HIV-infect­ed patients remains rare — 0.2% of interven­tions with extracorporeal circulation (ECC) in La Pitie Institute — and has some particu­larities, the majority of cardiac surgeons believe that the surgical strategies and tech­niques should be the same for HIV-infected patients as for other patients.

Although some standard cardiac operations have been performed on asymptomatic and unknown HIV-infected patients, the first deliberate open-heart operation on a patient known to be infected with HIV was per­formed by Frater et al. in December 1984 for tricuspid endocarditis in a bisexual heroin addict [1-3]. During the 1980s, the indica­tions for cardiac surgery in AIDS patients were limited to urgent life-threatening condi­tions: severe infectious endocarditis and tam­ponade [4]. These urgent indications are still frequent in patients with advanced AIDS, but standard elective cardiac surgery in asymptomatic HIV-infected patients is increasing proportionally.

From the beginning of the AIDS pandemic, surgical teams were faced with unusual ques­tions in this new and very peculiar popula­tion of patients, whose main characteristic was that they were young. The first questions were about the feasibility of surgery in patients with severe immunodeficiency and the benefit of surgery in patients with poor short-term prognosis. Other questions con­cerned the risk of HIV transmission from the patient to the surgical staff and vice versa during surgery. The risk of blood-borne virus transmission between the patient and the surgical team is now well known and fortu­nately low after the adoption of universal precautions.

We can now briefly answer the first and sec­ond questions: surgery, even complex cardiac surgery with ECC, is feasible in patients with severe immunodeficiency with higher but tolerable mortality; however, the benefit is low a fortiori in patients with uncontrolled HIV and opportunistic infections. Every sur­geon agrees that a life-threatening lesion, despite poor conditions in HIV-infected patients, should be operated on, but thanks to HAART, this situation is now less fre­quently encountered, and a new question arises: how to operate on a patient with HIV- controlled infection and good long-term prognosis?

Today, this disease is considered to be a chronic illness. For this reason, it is reason­able to expect an increasing number of HIV- infected patients who will require heart sur­gery. Cardiac surgeons should be prepared to manage these patients.