Elective Noncardiac Surgery With Severe LV Systolic Dysfunction
Elective noncardiac surgery is not automatically prohibited solely based on an LVEF of 20%, but it is associated with substantially higher perioperative mortality risk compared with patients without heart failure. [1] Proceeding with elective surgery generally requires confirmation of clinical stability, optimization of guideline-directed therapy for heart failure, and perioperative hemodynamic management by an experienced multidisciplinary team. [1]
Risk Magnitude for LVEF <30%
In patients undergoing noncardiac surgery, crude 90-day mortality was 8.34% for those with LVEF <30%. [1] In the same analysis, adjusted odds for 90-day mortality were increased for LVEF <30% (adjusted OR 2.35). [1]
Preoperative Clinical Stability Assessment
In patients with new dyspnea, physical examination findings of heart failure, or suspected new or worsening ventricular dysfunction undergoing noncardiac surgery, preoperative evaluation of left ventricular function is recommended to help guide perioperative management. [1] In patients with worsening dyspnea or other changes in clinical status with known heart failure undergoing noncardiac surgery, preoperative assessment of LV function is reasonable to help guide perioperative management. [1] In asymptomatic and clinically stable patients undergoing noncardiac surgery, routine preoperative evaluation of LV function is not recommended due to lack of benefit. [1]
Heart Failure Medical Therapy Optimization
For patients with heart failure undergoing elective noncardiac surgery, SGLT2 inhibitors should be withheld for 3 to 4 days before surgery when feasible to reduce the risk of perioperative metabolic acidosis. [1] For patients with compensated heart failure undergoing noncardiac surgery, it is reasonable to continue guideline-directed medical therapy in the perioperative period (excluding SGLT2 inhibitors), unless contraindicated, to reduce the risk of worsening heart failure. [1]
Perioperative Hemodynamic Targets
Maintaining intraoperative mean arterial pressure (MAP) ≥60 to 65 mm Hg or systolic blood pressure (SBP) ≥90 mm Hg is recommended to reduce the risk of myocardial injury. [1] Treatment of hypotension in the postoperative period (MAP <60–65 or SBP <90 mm Hg) is recommended to limit cardiovascular, cerebrovascular, renal events, and mortality. [1]
Selection for Additional Cardiac Testing
In patients undergoing elevated-risk noncardiac surgery with poor or unknown functional capacity and elevated risk for perioperative cardiovascular events based on a validated risk tool, stress testing may be considered to evaluate for inducible myocardial ischemia (Class 2b, B-NR). [1]
Practical Interpretation for LVEF 20%
An LVEF of 20% falls within the LVEF <30% category associated with higher 90-day mortality after noncardiac surgery. [1] Elective surgery is generally approached as high risk and is typically performed only after assessment of whether heart failure is clinically stable and after optimization of perioperative heart failure management and hemodynamics. [1]