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Published on: November 28, 2018
Outcome of cardiac surgery in patients with low preoperative ejection fraction
Marina Pieri1, Alessandro Belletti1, Fabrizio Monaco1
1Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
Insights
Patients with reduced left ventricular ejection fraction (LVEF) undergoing cardiac surgery face higher risks. Mitral valve surgery is linked to increased mortality, emphasizing careful patient selection and management for better outcomes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Outcomes
Background:
- Reduced preoperative left ventricular ejection fraction (LVEF) is common in cardiac surgery patients, correlating with poorer outcomes.
- Existing data often focus on specific procedures like coronary artery bypass graft (CABG), limiting understanding for diverse cardiac surgeries.
Purpose of the Study:
- To investigate the perioperative outcomes of a broad range of cardiac surgical procedures in patients with low preoperative LVEF.
- To identify specific procedures and patient factors associated with adverse outcomes in this high-risk group.
Main Methods:
- Retrospective analysis of 781 patients with preoperative LVEF ≤40% undergoing various cardiac surgeries.
- Subgroup analysis for patients with LVEF ≤30%.
Main Results:
- Overall perioperative mortality was 5.6%. Mitral valve surgery was associated with higher mortality compared to CABG.
- Complication rates, including low cardiac output syndrome and acute kidney injury, were elevated in patients with LVEF ≤30%.
- Independent predictors of mortality included COPD, preoperative intra-aortic balloon pump, and need for inotropes.
Conclusions:
- Cardiac surgery is feasible in patients with low LVEF, but they remain at higher risk for complications.
- Mitral valve surgery warrants particular attention due to higher associated mortality.
- Optimizing patient selection, risk assessment, and perioperative management is crucial for improving outcomes.
Background:
In patients undergoing cardiac surgery, a reduced preoperative left ventricular ejection fraction (LVEF) is common and is associated with a worse outcome. Available outcome data for these patients address specific surgical procedures, mainly coronary artery bypass graft (CABG). Aim of our study was to investigate perioperative outcome of surgery on patients with low pre-operative LVEF undergoing a broad range of cardiac surgical procedures.
Methods:
Data from patients with pre-operative LVEF ≤40 % undergoing cardiac surgery at a university hospital were reviewed and analyzed. A subgroup analysis on patients with pre-operative LVEF ≤30 % was also performed.
Results:
A total of 7313 patients underwent cardiac surgery during the study period. Out of these, 781 patients (11 %) had a pre-operative LVEF ≤40 % and were included in the analysis. Mean pre-operative LVEF was 33.9 ± 6.1 % and in 290 patients (37 %) LVEF was ≤30 %. The most frequently performed operation was CABG (31 % of procedures), followed by mitral valve surgery (22 %) and aortic valve surgery (19 %). Overall perioperative mortality was 5.6 %. Mitral valve surgery was more frequent among patients who did not survive, while survivors underwent more frequently CABG. Post-operative myocardial infarction occurred in 19 (2.4 %) of patients, low cardiac output syndrome in 271 (35 %). Acute kidney injury occurred in 195 (25 %) of patients. Duration of mechanical ventilation was 18 (12-48) hours. Incidence of complications was higher in patients with LVEF ≤30 %. Stepwise multivariate analysis identified chronic obstructive pulmonary disease, pre-operative insertion of intra-aortic balloon pump, and pre-operative need for inotropes as independent predictors of mortality among patients with LVEF ≤40 %.
Conclusions:
We confirmed that patients with low pre-operative LVEF undergoing cardiac surgery are at higher risk of post-operative complications. Cardiac surgery can be performed with acceptable mortality rates; however, mitral valve surgery, was found to be associated with higher mortality rates in this population. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcome.
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