Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.
JAMA Surg. 2019 Oct 1;154(10):907-914. doi: 10.1001/jamasurg.2019.2110.
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.
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).
Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery.
The primary outcomes were postoperative mortality at 90 days and any postoperative complication at 30 days.
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).
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.
心力衰竭是术后死亡的既定危险因素，但心力衰竭如何与特定于门诊手术环境的手术结果相关，目前尚不清楚。
评估在接受门诊手术的患者中，无论左心室收缩功能障碍的超声心动图（左心室收缩功能障碍）和临床（症状）严重程度如何，心力衰竭患者与无心力衰竭患者在术后死亡率和并发症方面的风险。
设计、地点和参与者：在这项美国退伍军人事务部手术质量改进项目数据库中，对 2009 年至 2016 年期间接受门诊、择期、非心脏手术的所有成年患者进行了多站点回顾性队列研究，共确定了 355121 例患者记录，并在手术后 1 年进行了随访（最后随访日期为 2017 年 9 月 1 日）。
心力衰竭、左心室射血分数以及手术前 30 天内是否存在心力衰竭的体征或症状。
主要结局是术后 90 天的死亡率和术后 30 天的任何并发症。
在 355121 名患者中，对 19353 名有心力衰竭（5.5%；平均[SD]年龄 67.9[10.1]岁；18841[96.9%]名男性）和 334768 名无心力衰竭（94.5%；平均[SD]年龄 57.2[14.0]岁；301198[90.0%]名男性）患者的结局数据进行了分析。与无心力衰竭的患者相比，有心力衰竭的患者术后 90 天死亡率风险更高（粗死亡率风险为 2.00%比 0.39%；调整后的优势比[aOR]为 1.95；95%CI，1.69-2.44），且收缩功能越低，死亡率风险越高。与无心力衰竭的患者相比，有症状的心力衰竭患者的死亡率风险更高（粗死亡率风险为 3.57%；aOR 为 2.76；95%CI，2.07-3.70），无症状的心力衰竭患者也是如此（粗死亡率风险为 1.85%；aOR 为 1.85；95%CI，1.60-2.15）。与无心力衰竭的患者相比，有心力衰竭的患者发生术后 30 天并发症的风险更高（粗风险为 5.65%比 2.65%；aOR 为 1.10；95%CI，1.02-1.19）。
在这项研究中，在接受择期门诊手术的患者中，无论有无症状，心力衰竭均与 90 天死亡率和 30 天术后并发症显著相关。这些数据可能有助于与接受门诊手术的心力衰竭患者进行术前讨论。
