Impact of Subclinical Congestion on Outcome of Patients Undergoing Mitral Valve Surgery

Abstract

Since risk assessment prior to cardiac surgery is based on proven but partly unsatisfactory scores, the need for novel tools in preoperative risk assessment taking into account cardiac decompensation is obvious. Even subclinical chronic heart failure is accompanied by an increase in plasma volume. This increase is illustrated by means of a plasma volume score (PVS), calculated using weight, gender and hematocrit. A retrospective analysis of 187 consecutive patients with impaired left ventricular function undergoing mitral valve surgery at a single centre between 2013 and 2016 was conducted. Relative preoperative PVS was generated by subtracting the ideal from actual calculated plasma volume. The study population was divided into two cohorts using a relative PVS score > 3.1 as cut-off. Patients with PVS > 3.1 had a significantly higher need for reoperation for bleeding/tamponade (5.5% vs. 16.7%; p = 0.016) and other non-cardiac causes (9.4% vs. 21.7%; p = 0.022). In-hospital as well as 6-month, 1-year and 5-year mortality was significantly increased in PVS > 3.1 (6.3% vs. 18.3%; p = 0.013; 9.4% vs. 23.3%; p = 0.011; 11.5% vs. 23.3%; p = 0.026; 18.1% vs. 33.3%; p = 0.018). Elevated PVS above the defined cut-off used to quantify subclinical congestion was linked to significantly worse outcome after mitral valve surgery and therefore could be a useful addition to current preoperative risk stratification.

Estimated plasma volume status in heart failure: clinical implications and future directions

“…In a retrospective cohort study including 1,887 patients undergoing coronary artery bypass graft surgery, preoperative assessment of Hakimderived ePVS ≥5.6% was associated with worse prognosis in a post-operative period 54 . Similarly, worse prognostic value of higher ePVS was reported in patients undergoing transaortic valvular intervention or mitral valvular intervention 55,56 . In addition, in 1,369 acute dyspneic patients admitted to the emergency department, the highest tertiles of admission Duarte-derived ePVS was associated with AHF diagnosis (adjusted OR [95%CI]=1.64 [1.16-2.33], p=0.005) as the main cause of dyspnea.…”

Deviations From the Ideal Plasma Volume and Isolated Tricuspid Valve Surgery—Paving the Way for New Risk Stratification Parameters

“…The association of PVS with outcomes following TAVR was also demonstrated by Seoudy et al (33). A study by Schaefer et al examined the association between PVS and mortality following mitral valve surgery (34).…”

“…Seoudy et al identified an ePVS cut-off of −5.4 as a significant predictor of these outcomes in a TAVI cohort at 1 year after the intervention (33). Interestingly, Schaefer et al identified a higher ePVS cut-off of 3.1 when analyzing the correlation of the calculated plasma volume status with shortand long-term outcomes in patients undergoing mitral valve surgery (34). In summary, the ePVS cut-off identified by our study is in agreement with data from other trials in different patient collectives and thus provides initial proof that, on the one hand, ePVS might represent a viable stratification parameter for patients undergoing isolated tricuspid valve surgery, and on the other hand, ePVS might represent an overarching heart failurerelated stratification parameter that might play a key role in identifying at-risk cardiac surgery patients undergoing a number of different interventions.…”