Rethinking ejection fraction for anesthesiologists: a narrative review

Left ventricular ejection fraction (EF) is one of the most frequently cited cardiac parameters in perioperative risk assessment and is often used as a surrogate marker of global cardiac stability. However, EF was validated primarily in chronic cardiovascular disease and long-term heart failure management, raising important questions about its suitability as a dominant marker of short-term perioperative risk. EF does not capture key determinants of perioperative vulnerability, including diastolic function, ventricular compliance, right ventricular function, venous congestion, or contractile reserve. Contemporary clinical data suggest that only severely reduced EF (< 30%) is consistently associated with markedly increased perioperative risk, whereas mildly to moderately reduced EF in clinically stable patients often carries less prognostic significance than preserved EF in the presence of heart failure with preserved ejection fraction (HFpEF), congestion, or right ventricular dysfunction. Common perioperative scenarios such as HFpEF, distributive shock, hypovolemia, venous congestion, and chronic compensated heart failure illustrate that EF may substantially underestimate or overestimate true hemodynamic vulnerability depending on the physiological context. In contrast, functional capacity, volume status, and clinical stability emerge as more robust determinants of short-term perioperative risk. Advanced echocardiographic parameters, including diastolic indices, global longitudinal strain (GLS), and focused assessment of right ventricular function, together with biomarkers provide a more physiologically coherent risk profile. The uncritical use of EF as a primary perioperative risk marker is not supported by current evidence. For anesthesiologists, EF should be interpreted as one component within a multidimensional, physiology-guided assessment that integrates focused perioperative ultrasound, clinical history, and targeted biomarkers to more accurately characterize perioperative cardiovascular risk.