Perioperative Outcome and Long‐Term Mortality for Heart Failure Patients Undergoing Intermediate‐ and High‐Risk Noncardiac Surgery: Impact of Left Ventricular Ejection Fraction

Abstract

The impact of left ventricular ejection fraction (EF) on outcome in patients with heart failure (HF) undergoing non-cardiac surgery has not been extensively evaluated. 174 subjects (mean age 75±12 years, 47% male, mean EF (47±18%) underwent intermediate or high risk non-cardiac surgery. Patients were stratified by EF and adverse perioperative complications were identified and compared. Adverse perioperative events occurred in 53 (30.5%) of subjects, including 14 (8.1%) deaths within 30 days, 26 (14.9%) myocardial infarctions, and 44 (25.3%) HF exacerbations. Among the factors associated with adverse perioperative outcomes in the first 30 days were advanced age (e.g. >80 years), diabetes and a severely decreased EF (e.g. <30%). Long term mortality was high and Cox proportional hazards analysis demonstrated that EF was an independent risk factor for long term mortality.

The patient with chronic heart failure undergoing surgery

“…Increased risk of death and/or major adverse cardiac events (MACEs) among patients undergoing noncardiac surgery has been demonstrated in patients with a history/signs of heart failure (relative risk 3.4) [6,11]. Other factors associated with preoperative MACE are a decreased LVEF with the highest risk group being those with an LVEF < 30% [6,11]. Preoperatively, most commonly measured laboratory tests are brain natriuretic peptide (BNP) or NT-pro-BNP and both are found to predict perioperative and in-hospital MACEs as well as short-term mortality [11].…”

“…Clinical symptoms of CHF are fatigue, dyspnea, orthopnea and reduced exercise tolerance often combined with signs of peripheral and/or lung edema [4][5][6]. In contrast to patients with coronary artery disease, CHF is often not adequately diagnosed and clinical signs should therefore be carefully evaluated…”

Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery

“…14 Prognosis for survival in patients undergoing high or intermediate risk noncardiac or cardiac surgery is significantly worse in patients with depressed LVEF. 27,35,69 This is a key factor in noncardia surgery patients, and one that not emphasised enough in most guidelines. It is definitely an element to consider in risk reduction strategies.…”

Heart failure is associated with reduced patency after endovascular intervention for symptomatic peripheral arterial disease

“…[2][3][4][5] Heart failure is a known risk factor for perioperative morbidity and mortality after major surgery, and patients with CHF and the comorbidities frequently associated with it may preferentially be offered endovascular intervention in lieu of surgical bypass for severe claudication or critical limb ischemia. 6,7 However, outcomes in this patient population have not been examined specifically. Theoretically, patients with CHF may be at elevated risk for diminished patency of endovascular therapy for symptomatic PAD due to hemodynamic and physiologic alterations that include a low-flow state, increased peripheral resistance, endothelial cell dysfunction, and vascular smooth muscle cell dysfunction.…”