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Original Investigation
Pacific Coast Surgical Association
July 10, 2019

Association Between Heart Failure and Postoperative Mortality Among Patients Undergoing Ambulatory Noncardiac Surgery

Author Affiliations
  • 1Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 2Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 3Section of Cardiology, Medical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
  • 4Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
  • 5Department of Surgery, Stanford University School of Medicine, Stanford, California
JAMA Surg. Published online July 10, 2019. doi:10.1001/jamasurg.2019.2110
Key Points

Question  What is the association between severity of heart failure and risk of postoperative mortality among patients undergoing ambulatory surgery?

Findings  In this cohort study of 355 121 patients undergoing ambulatory surgery, the crude 90-day mortality was 2.00% among patients with heart failure and 0.39% among patients without heart failure. The crude risk of 30-day postoperative complications was 5.7% among patients with heart failure and 2.7% among patients without heart failure.

Meaning  Heart failure with or without symptoms was associated with increased risk of 90-day mortality and 30-day postoperative complications.

Abstract

Importance  Heart failure is an established risk factor for postoperative mortality, but how heart failure is associated with operative outcomes specifically in the ambulatory surgical setting is not well characterized.

Objective  To assess the risk of postoperative mortality and complications in patients with vs without heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity who were undergoing ambulatory surgery.

Design, Setting, and Participants  In this US multisite retrospective cohort study of all adult patients undergoing ambulatory, elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database during fiscal years 2009 to 2016, a total of 355 121 patient records were identified and analyzed with 1 year of follow-up after surgery (final date of follow-up September 1, 2017).

Exposures  Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery.

Main Outcomes and Measures  The primary outcomes were postoperative mortality at 90 days and any postoperative complication at 30 days.

Results  Among 355 121 total patients, outcome data from 19 353 patients with heart failure (5.5%; mean [SD] age, 67.9 [10.1] years; 18 841 [96.9%] male) and 334 768 patients without heart failure (94.5%; mean [SD] age, 57.2 [14.0] years; 301 198 [90.0%] male) were analyzed. Compared with patients without heart failure, patients with heart failure had a higher risk of 90-day postoperative mortality (crude mortality risk, 2.00% vs 0.39%; adjusted odds ratio [aOR], 1.95; 95% CI, 1.69-2.44), and risk of mortality progressively increased with decreasing systolic function. Compared with patients without heart failure, symptomatic patients with heart failure had a greater risk of mortality (crude mortality risk, 3.57%; aOR, 2.76; 95% CI, 2.07-3.70), as did asymptomatic patients with heart failure (crude mortality risk, 1.85%; aOR, 1.85; 95% CI, 1.60-2.15). Patients with heart failure had a higher risk of experiencing a 30-day postoperative complication than did patients without heart failure (crude risk, 5.65% vs 2.65%; aOR, 1.10; 95% CI, 1.02-1.19).

Conclusions and Relevance  In this study, among patients undergoing elective, ambulatory surgery, heart failure with or without symptoms was significantly associated with 90-day mortality and 30-day postoperative complications. These data may be helpful in preoperative discussions with patients with heart failure undergoing ambulatory surgery.

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