The patient with chronic heart failure undergoing surgery

Abstract

Purpose of review: Congestive heart failure (CHF) is one of the most common diseases of the elderly patient. The underlying pathophysiology varies considerably and approximately 50% of the patients suffer from CHF with reduced left ventricular ejection fraction. Mortality in the perioperative period is increased in patients with CHF and this holds true for both minor and major surgeries. This review will summarize recent literature in the field of CHF and perioperative outcome in patients undergoing surgery with a special emphasis on actual guidelines, preoperative assessment and appropriate perioperative therapy.

Recent findings: In the past 18 months, new insights in the short and long-term effects of CHF in the perioperative period have been published. The role of left ventricular ejection fraction has been studied in noncardiac surgical patients and it has been demonstrated that an ejection fraction less than 30% is associated with a significant increase in mortality and myocardial infarctions. Moreover, in 25% of patients, acute exacerbation of heart failure takes place in the perioperative period. The European Society of Anesthesiology published new guidelines on the preoperative evaluation of patients with CHF. The role of adequate preoperative evaluation and preparation of patients with CHF is discussed widely. It becomes clear that parameters like brain natriuretic peptide play a crucial role in risk stratification and prediction of outcome. Also, the treatment of patients with low cardiac output was a topic, and it became clear that established therapies including the use of β-mimetics and PDE-III inhibitors should only be initiated in very selected patient groups. However, adequately powered studies in patients with CHF are still missing and the majority of knowledge is based on patient undergoing cardiac surgery.

Summary: CHF is a source of considerable perioperative morbidity and mortality and in contrast to coronary artery disease, knowledge is very limited and additional research urgently needed.