Abstract
Since risk assessment prior to cardiac surgery is based on proven but partly unsatisfactory scores, the need for novel tools in preoperative risk assessment taking into account cardiac decompensation is obvious. Even subclinical chronic heart failure is accompanied by an increase in plasma volume. This increase is illustrated by means of a plasma volume score (PVS), calculated using weight, gender and hematocrit. A retrospective analysis of 187 consecutive patients with impaired left ventricular function undergoing mitral valve surgery at a single centre between 2013 and 2016 was conducted. Relative preoperative PVS was generated by subtracting the ideal from actual calculated plasma volume. The study population was divided into two cohorts using a relative PVS score > 3.1 as cut-off. Patients with PVS > 3.1 had a significantly higher need for reoperation for bleeding/tamponade (5.5% vs. 16.7%; p = 0.016) and other non-cardiac causes (9.4% vs. 21.7%; p = 0.022). In-hospital as well as 6-month, 1-year and 5-year mortality was significantly increased in PVS > 3.1 (6.3% vs. 18.3%; p = 0.013; 9.4% vs. 23.3%; p = 0.011; 11.5% vs. 23.3%; p = 0.026; 18.1% vs. 33.3%; p = 0.018). Elevated PVS above the defined cut-off used to quantify subclinical congestion was linked to significantly worse outcome after mitral valve surgery and therefore could be a useful addition to current preoperative risk stratification.
Highlights
IntroductionWhile contemporary cardiothoracic surgical risk models are mainly based on the evaluation of left ventricular ejection fraction, which is often overestimated in patients with higher degrees of mitral valve insufficiency, newly developed assessment tools for chronic heart failure and cardiac decompensation might substantially aid preprocedural risk assessment as well as planning and timing of the procedure
While contemporary cardiothoracic surgical risk models are mainly based on the evaluation of left ventricular ejection fraction, which is often overestimated in patients with higher degrees of mitral valve insufficiency, newly developed assessment tools for chronic heart failure and cardiac decompensation might substantially aid preprocedural risk assessment as well as planning and timing of the procedure.As mitral regurgitation (MR) inherently leads to left ventricular dilatation via increased filling pressures and refractory volume overload, chronic heart failure (CHF) is a common concomitant factor of patients referred for surgical mitral valve repair with significant impact on postprocedural outcome [1,2,3,4]
Above 3.1 is an independent predictor of in-hospital mortality in a multivariable analysis (II) that patients with an elevated plasma volume status (PVS) were prone to re-operations and prolonged postprocedural ventilation and (III) that a high preprocedural PVS is an indicator for impaired long-term survival over 5 years
Summary
While contemporary cardiothoracic surgical risk models are mainly based on the evaluation of left ventricular ejection fraction, which is often overestimated in patients with higher degrees of mitral valve insufficiency, newly developed assessment tools for chronic heart failure and cardiac decompensation might substantially aid preprocedural risk assessment as well as planning and timing of the procedure. As mitral regurgitation (MR) inherently leads to left ventricular dilatation via increased filling pressures and refractory volume overload, chronic heart failure (CHF) is a common concomitant factor of patients referred for surgical mitral valve repair with significant impact on postprocedural outcome [1,2,3,4]. A well-known consequence of CHF is an increase in plasma volume triggering acute decompensation with a significant impact on the prognosis of these patients [5,6]. An elevated PVS is known to directly correlate with increased mortality in patients with stable CHF, and has been applied for risk stratification in patients undergoing coronary artery bypass graft surgery or transcatheter aortic valve replacement [8,9].
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