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What is the Relationship Between Chronic Heart Failure and Operation size? A systematic Review

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Research Article | DOI: https://doi.org/10.31579/2768-2757/064

What is the Relationship Between Chronic Heart Failure and Operation size? A systematic Review

  • Lucinda Cruddas *
  • Daryll M. Baker

Vascular Surgery, Royal Free Hospital, London, United Kingdom.

*Corresponding Author: Lucinda Cruddas, Vascular Surgery, Royal Free Hospital, London, United Kingdom.

Citation: Cruddas L., Daryll M. Baker. (2023). What is the Relationship between Chronic Heart Failure and operation size? A systematic Review. Journal of Clinical Surgery and Research, 4(1); DOI:10.31579/2768-2757/064

Copyright: © 2023 Lucinda Cruddas. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 28 December 2022 | Accepted: 04 January 2023 | Published: 09 February 2023

Keywords: heart failure; morbidity; mortality; perioperative risk; surgery

Abstract

Background:

Heart failure is a chronic progressive failure of the heart muscle to pump blood to meet the body’s oxygen demands. Heart failure impacts on perioperative outcomes of non-cardiac surgery, with higher risks of post-operative complications and mortality. The aim of this study was to review current clinical evidence to assess if there was a relationship between heart failure, operation size and post operative outcomes

Methods:

PRISMA guidelines were implemented to complete a systematic review. The review was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022313897). PubMed was searched from 1940 to 2022 using the terms “heart failure”, “noncardiac surgery”, “thyroid surgery”, “breast surgery”, “asymptomatic carotid endarterectomy”, “hernia”, “cholecystectomy”. “laparoscopy”, laparotomy”, “peripheral angioplasty”, “EVAR”, “neck of femur”, “abdominal aortic aneurysm”, and “lower extremity revascularisation”. Inclusion criteria included: experimental and observational studies; pre operative diagnosis of heart failure; 30d morbidity and mortality; non cardiac surgery. 

Results:

47 articles relevant to the inclusion criteria were analysed. Five studies assessed low risk operations; 29 assessed intermediate risk operations; 8 assessed high risk operations; 5 assessed intermediate and high-risk operations. For low, intermediate and high-risk operations, heart failure was associated with a statistically significant increased risk of mortality and morbidity (p lessthan0.05). 

Conclusions:

Heart failure is associated with increased morbidity and mortality independent of operation size or risk. Challenges remain in assessing the relationship between heart failure and operation outcome due to variations in disease spectrum and the impact of additional co-morbidities.

Introduction

Heart failure is a physiological failure of the heart pump to meet the body’s demands for oxygen. It is diagnosed as a constellation of signs and symptoms, and a demonstrated reduced left ventricular ejection function (LVEF) or preserved LVEF with structural disease and/or diastolic dysfunction, on echocardiogram [1]. Symptoms include breathlessness, fatigue and reduced exercise tolerance. Clinical signs of right sided heart failure include peripheral oedema, whilst left sided heart failure is characterised by signs of pulmonary oedema including tachypnoea, raised jugular venous pressure and reduced oxygen saturations. Heart failure is common, and in developed countries, affects graterthan10percentage of the population graterthan70 years old [2]. It is a progressive condition although has an unpredictable course [3]. Heart failure can be categorised using either ACC/AHA classification (Table 1) [4] or New York Heart Association (NYHA) functional classification (Table 2) [5].

Table 1: American College of Cardiology/ American Heart Association time line classification of heart failure

Table 2: New York Heart Association (NYHA) classification of heart failure

Heart failure impacts on perioperative outcomes of non-cardiac surgery. Patients with heart failure have been shown to have a higher risk of 90-day post-operative mortality and 30-day post-operative complications, than patients without heart failure [6,7,8,9,10,11]. This risk is proportional, and mortality risk increases as systolic function decreases [6,12,13] or in cases of acute heart failure [9]. Increased mortality is also observed in both elective and emergency non-cardiac procedures [7,14]. The rates of post-operative mortality may be higher in woman than men with heart failure [11]. Overall, the mechanism of increased mortality is poorly understood. 

Alongside increased mortality, patients with heart failure undergoing non-cardiac surgery suffer increased post-operative morbidity. Post-operative cardiac events are more frequent in patients with heart failure [15,16,17,18,19,20]. This is the case for patients with reduced right heart function, as well as patients with lower LVEF [21,22]. Cardiac complications are associated with longer inpatient stays, death and higher costs [16,17]. As well as cardiac complications, patients with heart failure are at increased risk of post-operative pulmonary embolism, acute renal failure, need for mechanical ventilation for over 48 hours, unplanned intubation, cerebrovascular event, pneumonia, urinary tract infection, sepsis and admission to intensive care [20,23,24]. These patients are more likely to require hospital readmission [7]. This highlights the importance of identification of patients with heart failure, and their optimisation during the perioperative period. 

Materials and methods:

A systematic review of articles was performed to assess outcomes of patients with heart failure for different operations, based on the Preferred Report Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The review was registered with PROSPERO (ID CRD42022313897).

Inclusion and Exclusion Criteria:

In this review, the relationship between heart failure and size of operation was assessed by classifying operations as low, intermediate or high risk (Table 3). The relationship was assessed in the perioperative and immediate post-operative period (30-day post procedure). Patient morbidity and mortality were assessed as opposed to the long-term operative success. Outcomes were assessed in individuals with heart failure, compared to those without heart failure. 

Inclusion criteria:

  • Experimental and observational studies
  • Outcomes for patients diagnosed with heart failure preoperatively
  • Outcomes in the perioperative and immediate post-operative period (30 days)
  • Non-cardiac surgeries

Exclusion criteria:

  • Case reports
  • Heart failure assessed as a component of a score, or combined with other co-morbidities
  • Assessment of coronary artery disease or ischaemic heart disease without reference to heart failure
  • Cardiac surgery and type A dissection 

Search methods and selection of studies:

Pubmed was searched from 1940 to 2022 based on the following search terms: “heart failure”, “ noncardiac surgery”, “thyroid surgery”, “breast surgery”, “asymptomatic carotid endarterectomy”, “hernia”, “cholecystectomy”. “laparoscopy”, laparotomy”, “peripheral angioplasty”, “EVAR”, “neck of femur”, “abdominal aortic aneurysm”, and “lower extremity revascularisation”. These terms were selected following the definition of these surgeries as low, intermediate and high risk (Table 3). Each of these terms was searched independently alongside “heart failure”. No filters or limits were applied. Analysis of paper screening and selection was demonstrated (Figure 1).

Table 3: Estimation of surgical risk according to procedure [adapted from 30]

Figure 1: PRISMA flow chart for selection of papers for review

Each search was performed independently by the two lead authors to avoid bias, and articles which did not meet the inclusion criteria were rejected. Paper title and abstracts were assessed for relevance independently by the two authors, and full texts were examined in cases where relevance was not clear from this initial screen. Selected articles were read and rejected if they did not meet the inclusion criteria. This data was extracted from included papers and transferred to an Excel spreadsheet, and collated into tables (Tables 4,5,6). 

Table 4: Table demonstrating relationship between heart failure and post-operative morbidity and mortality in low risk surgeries

StudyType of studyStudy periodOperationNumber of participantsMorbidityMorbidity statisticsIncreased 30d mortality
[34]Prospective multicentre national database2009-2010Ventral and incisional hernia: emergency; elective28,286Prolonged length of stay for incarcerated/strangulated hernias following ventral/ inguinal hernia repair

Plessthan0.040

 

-
[35]Prospective multicentre2008-2014Elective ventral hernia:  open; laparoscopic103,635--

OR= 2.15 95percentage CI 1.32-3.47

P=0.002

[36]Prospective multicentre national database2007-2008Inguinal hernia: open, laparoscopic, emergency and elective2,377Wound complications, pulmonary complications, urinary tract complications, cardiac complicationsOR 4.3 95percentage CI 1.5-12.6-
[37]Prospective multicentre national database2007-2015Cholecystectomy: open and laparoscopic478,111Hospital length of stayPlessthan0.001

OR 1.31 95percentage CI

1.16-1.48

Plessthan0.001

[38]Prospective multicentre national database2008-2012Elective and emergency laparoscopic cholecystectomy143,761Pneumonia or reintubationPlessthan0.01Plessthan0.01
[39]Prospective multicentre national database1998-2016Cholecystectomy: open and laparoscopic

282,184

 

Pneumonia

OR 1.965

95percentage CI 1.587-2.438

Plessthan0.0001

-
[40]Prospective multicentre national database2009-2010Cholecystectomy: open and laparoscopic53,63230d readmission

OR 2.1 95percentage CI

1.8-2.4

Plessthan0.0001

-
[41]Prospective single centre1993-2006Elective laparoscopic sigmoid resection for diverticular disease526Post operative medical complications (pneumonia, pulmonary embolism, thrombosis, cardiac failure or infarction, renal failure)

OR 3.27 95percentage CI

(1.37-7.8)

Plessthan0.008

-
[42]Prospective multicentre database2005-2012Bariatric surgery: laparoscopic; open;102,869Post operative pulmonary embolism (PE) (laparoscopy)

OR 6.03

95percentage CI 1.45-25.10

Plessthan0.014

-
Post operative deep vein thrombosis (DVT) (laparoscopy)

OR 4.64

CI 95percentage

1.13-19.11

Plessthan0.034

Post operative PE (open)

OR 10.32

CI 95percentage

1.29-82.65

Plessthan0.028

Post operative DVT (open)

OR 7.72

CI 95percentage (0.97-61.49)

Plessthan0.053

[43]Prospective multicentre database2004-2007

Elective left-colon resection, colostomy, ileostomy for diverticulitis

 

 

22,752

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemorrhage

OR 1.5

95percentage CI 1.69-2.27

OR 3.5

95percentage CI 2.59-4.63

 

 

Wound

OR 1.9

95percentage CI 1.50-2.39

Pulmonary

OR 4.2

95percentage CI 3.59-4.85

Cardiac

OR 4.6

95percentage CI 3.68-5.74

Sepsis

OR 3.2

95percentage CI 2.53-4.35

Renal

OR 4.1

95percentage CI 3.22-5.12

Thromboembolic

OR 1.6

95percentage CI 1.00-2.50

[44]Prospective multicentre1993-1999Elective colectomy via laparotomy1721Colorectal cancer morbidity

OR 3.0 CI 95percentage 1.42-6.32

P=0.003

-
[45]Prospective multicentre2005-2007All abdominal surgeries202Surigcal site infection

OR 1.9

95percentage CI

1.20-3.04

P=0.011

-
[46]Prospective multicentre1997-2009Damage control laparotomy with open abdomen for acute general and vascular67--

OR 11.4

95percentage CI 1.01-128.03

[47]Prospective multicentre database2015-2016EVAR, CEA, open AAA, peripheral bypass88,791Post operative MIPlessthan0.001-
[48]Prospective multicentre database2012-2017EVAR, CEA, open AAA, peripheral bypass26,231Post operative MI

OR 1.52

95percentage CI

1.16-1.98

 
[50]Prospective multicentre2012-2014Infrainguinal endovascualar intervention444930 day redmission

OR 1.6

CI 95percentage 1.1-2.5

-
[51]Prospective multicentre database1997-2010Percutaneous angioplasty for peripheral arterial disease7568--

OR 1.62 95percentage CI

1.32-1.98

[52]Prospective single centre2008-2017EVAR136Myocardial injury (post operative rise in troponin)P=0.016-
[53]Prospective multicentre database2003-2016Elective EVAR Major adverse event (MI, dysrhythmia, heart failure, leg ischaemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, no discharge home

OR 1.7 95percentage CI 1.5-1.9

P=0.001

-
[54]

Prospectivemulticentre database

 

2003-2017EVAR28,240In hospital event (MI, dysrhythmia, heart failure, stroke, pneumonia, respiratory failure, renal failure, lower extremity ischaemia, bowel ischaemia, reoperation

OR 2.20 CI 95percentage 1.64-2.95

Plessthan 0.001

-
[55]Prospectivemulticentre database2003-2014Elective EVAR3,979Prolonged intubationPlessthan0.05-
[56]Prospective two centre1995-1998EVAR113Adverse cardiac eventP = 0.005-
[57]Prospective multicentre database2005-2013EVAR21,769Protracted length of stayOR 1.8 CI 95percentage 1.4-2.4-
[58]Prospective multicentre database2012-2013EVAR388630 day readmissionPlessthan0.5-
[59]Prospective multicentre database2012-2014EVAR120,64630d readmission

OR 1.8  95percentage CI 1.4-2.3

Plessthan0.0001

-
[60]Prospective multicentre database2001-2004EVAR11,415--

OR 2.4 95percentage CI 1.8-3.4

Plessthan0.0001

[61]Prospectivemulticentredatabase2005-2010Elective EVAR11,229--Plessthan0.05
[63]Prospective multicentre database2014-2018Elective TEVAR1469Non home dischargePlessthan0.05-
[64]Prospective, multicentre database2006-2007 and 2009-2010Total hip replacement, total knee replacement, AAA repair429,509Readmission

OR 1.23

95percentage CI

1.28-1.38

Plessthan0.001

OR 6.79

95percentage CI

5.48-8.42

Plessthan0.001

Length of stay

OR 2.5

95percentage CI

2.31-2.71

Plessthan0.001

[65]Prospectivesingle centre2004-2018Repair hip fracture1992--

OR 4.01

95percentage CI 1.10-8.78

P=0.009

[66]Prospectivesingle centre2011-2014Repair hip fracture331--OR 6.2 CI 95percentage 1.8-20.9 P=0.003
[67]Prospectivesingle centre2009-2013Repair hip fracture99--P=0.036
[68]Prospectivemulticentre database2005-2016Total knee and hip replacement537PneumoniaP=0.003Plessthan0.001
Renal insufficiencyP=0.040
Myocardial infarctionP=0.050
Extended length of stay (graterthan5)Plessthan0.001
Readmission

OR 1.23

95percentage CI (1.09-1.39)

[69]Prospective single centre2013-2017Repair neck of femur fracture285Post operative akiPlessthan0.05-

Table 5: Table demonstrating relationship between heart failure and post-operative morbidity and mortality in intermediate risk surgeries

StudyType of studyStudy periodOperationNumber of participantsMorbidityMorbidity statisticsMortality statistics
[27]Prospective, multicentre database1997-1998Major non cardiac (abdominal, vascular, orthopaedic)23,340ReadmissionPlessthan0.001Plessthan0.001
[47]Prospective, multicentre database2015-2016Infrainguinal bypass, open AAA88,791Post op MIPlessthan0.08-
[56]Prospective two centre1995-1998Elective open AAA repair113Adverse cardiac eventP=0.001-
[60]Prospective multicentre database2001-2004Open AAA repair11,415--

OR 2.1 95percentage CI 1.7-2.6

Plessthan0.001

[64]Prospective multicentre database2006-2007 and 2009-2010AAA14,524Increased length of stay

OR 1.78 95percentage CI 1.46-2.16

Plessthan0.001

OR 3.54

95percentage CI

2.65-4.73

Plessthan0.001

Readmission

OR 1.47

95percentage CI

1.11-1.94

Plessthan0.006

[70]Prospective single centre1987-1988

AAA repair

 

72Post operative cardiac failureP=0.004Plessthan0.001
[71]Prospective single centre1991-2001Open TAA854--

Or 1.85 95percentage CI 1.09-3.15

P=0.03

[72]Prospective multicentre database2002-2014EVAR-c and primary open6429Major adverse cardiac eventOR 1.5 CI 95percentage 0.98-2.34-
[73]Prospective multicentre database2009-2015Open AAA repair and EVAR33,33230d readmissionPlessthan0.05-
[74]Prospective multicentre database2005-2010Infrainguinal bypass18,645Cardiac eventP=0.007

Plessthan0.0001

 

PneumoniaP=0.014
Prolonged intubationP=0.011
ReintubationP=0.014
SepsisP=0.011
Re-operationP=0.022
LOS graterthan9 daysP=0.0001
[75]Prospective multicentre database2013-2016Arterial reconstruction for revascularisation2906Major adverse limb event 30d after revascularisationOR 1.10 
[76]Prospective multicentre database2011-2013Infrainguinal bypass1,055--

OR 4.46

95percentage CI

1.20-16.57

Plessthan0.025

Table 6: Table demonstrating relationship between heart failure and post-operative morbidity and mortality in high risk surgeries

Data extraction included: study type; study period; operation performed; number of patients; morbidity; and mortality. Association of heart failure and post-operative morbidity and mortality was demonstrated by comparing patients with preoperative heart failure, and those without. Results were assessed for significance based on odds ratio, confidence interval and p value. 

Results:

PubMed identified 297 articles for “heart failure” and “noncardiac surgery”, 436 articles for “heart failure” and “breast surgery”, 371 articles for “heart failure” and “thyroid surgery”, 86 articles for “heart failure” and “asymptomatic carotid endarterectomy”, 206 articles for “heart failure” and “hernia”, 118 articles for “heart failure” and “cholecystectomy”, 276 articles for “heart failure” and “laparoscopy”, 253 articles for “heart failure” and “laparotomy”, 186 articles for “heart failure” and “peripheral angioplasty”,  90 articles for “heart failure” and EVAR”, 87 articles for “heart failure” and “neck of femur”, 1168 articles for “heart failure” and “aortic aneurysm”, and 145 articles for “heart failure” and “lower extremity revascularisation”. Articles were screened and duplicates removed. This led to the final inclusion of 47 articles. One study was included for thyroid surgery, 4 studies were included for asymptomatic carotid endarterectomy, 3 studies were included for hernia surgery, 4 studies were included for cholecystectomy, 3 studies were included for laparoscopy, 3 studies were included for laparotomy, 2 studies were included for peripheral angioplasty, 9 studies were included for EVAR, 5 studies were included for neck of femur fracture repairs, 4 studies were included for aortic aneurysm (AAA) repair, 3 studies were included for lower extremity revascularisation, and 1 study was included for noncardiac surgery. There were no studies which examined the relationship of outcomes of patients with heart failure undergoing breast surgery. One study assessed the relationship between heart failure and outcomes in both abdominal aortic aneurysm and hip/knee replacement. Two studies assessed the relationship between heart failure and outcomes in both open and endovascular abdominal aneurysm repair. Two papers looked at the relationship between heart failure and outcomes in all vascular operations (EVAR, peripheral bypass, open AAA repair). 

Results are demonstrated in Table 4 for low-risk surgeries, Table 5 for intermediate risk surgeries, and Table 6 for high-risk surgeries. 

Discussion:

Patients undergoing low, intermediate and high risk non-cardiac surgeries are at risk of increased morbidity and mortality [6, 26,27]. 

Heart failure and low risk surgeries:

There are limited studies on the outcomes of patients with heart failure undergoing low risk surgery. A large prospective, multi-centre national study of patients undergoing thyroid surgery showed that congestive heart failure was associated with increased risk of complications and return to the operating theatre (OR 6.83, 95percentage CI 1.81-25.80) [28]. In asymptomatic patients undergoing carotid endarterectomy (CEA), patients with congestive heart failure have been shown to have an increased risk of post-operative stroke and death [29,30,31].  In a large multicentre national prospective study, congestive heart failure was also a predictor of post-operative myocardial infarction in asymptomatic patients undergoing CEA (Plessthan0.001) [32]. Routine cardiology consultation may be of benefit in patients prior to surgery for asymptomatic CEA to reduce perioperative cardiac complications and mortality [33]. There is no literature to assess the impact of heart failure on the perioperative outcomes of breast surgery.

Heart failure and intermediate risk surgeries:

General surgery:

Heart failure has been shown to be associated with increased hospital length of stay (plessthan0.04) [34] and mortality (plessthan0.002) [35] in inguinal and ventral hernia repairs. One prospective multicentre study demonstrated that heart failure was associated with increased rates of wound, pulmonary, urinary tract and cardiac complications following hernia surgery (OR 4.3 95percentage CI 1.5-12.6) [36]. Heart failure has also been shown to impact on the perioperative and postoperative course of patients undergoing cholecystectomy. Patients with heart failure have been shown to have increased hospital length stays (plessthan0.001) [37], and increased rates of pneumonia and reintubation (plessthan0.01) [38,39] and post-operative readmission at 30 days (plessthan0.0001) [40]. This is the case in both elective and emergency procedures. 

Individuals with heart failure who undergo elective laparoscopic sigmoid resection for diverticular disease have been shown to suffer greater perioperative complications including pneumonia, pulmonary embolism, thrombosis, cardiac failure or infarction and renal failure (OR 3.27 95percentage CI 1.37-7.8 plessthan0.008) [41]. In a large prospective study assessing the outcomes of bariatric surgery, patients with heart failure have been shown to be more likely to suffer from post-operative DVT and PE [42]. Heart failure is likely to impact on the outcomes of intermediate laparoscopy and laparotomy. A large, prospective, multicentre study revealed that patients with heart failure are more likely to suffer post-operative mortality (OR 3.5 95percentage CI 2.59-4.63) and complications including haemorrhage, wound, pulmonary, cardiac, sepsis, renal and thromboembolic, following elective left colonic resection, with colostomy or ileostomy for diverticulitis [43]. Post-operative morbidity following elective colectomy via laparotomy for colon cancer has been shown to be significantly higher in patients with heart failure (OR 3.0 CI 95percentage 1.42-6.32 P=0.003) [44]. Heart failure may also be associated with a higher risk of surgical site infection following laparotomy (OR 1.9 95percentage CI 1.29-3.04) [45]. In damage control laparotomy, individuals with heart failure may be at higher risk of post-operative mortality (OR 11.4 95percentage CI 1.01-128.03) [46]. 

Vascular:

In all vascular procedures, classified as high and intermediate risk, patients with heart failure were more likely to suffer post-operative myocardial infarction [47,48]. Pre-operative cardiac assessment does not appear to improve outcomes [49]. Patients with heart failure may be at increased risk of unplanned 30-day re-admission (OR 1.6 CI 95percentage 1.1-2.5) [50] and increased mortality (OR 1.62 95percentage CI 1.32-1.98) [51] following endovascular peripheral angioplasty. In both elective and emergency endovascular aneurysm repair (EVAR), large prospective multi-institutional studies have demonstrated that heart failure is associated with increased risk of postoperative myocardial injury, pneumonia, heart failure, limb ischaemia, renal dysfunction, bowel complications, reoperation, surgical site infection, stroke, prolonged intubation, respiratory complications and discharge to a facility [47,48,51,53,54,55,56,57,58,59]. A large prospective multicentre database study has also demonstrated that heart failure is an independent predictor of mortality in patients undergoing EVAR (Plessthan0.05) [60,61]. Patients who are deemed unfit for open repair of their aneurysm and subsequently have EVAR, commonly have heart failure, and suffer greater post-operative cardiopulmonary complications and perioperative mortality [62]. Patients with heart failure who had a thoracic endovascular aortic repair (TEVAR) have also been shown to be at increased risk of discharge to a facility [63] (plessthan0.05).

Orthopaedic:

In individuals who underwent surgical fixation for a neck of femur fracture, heart failure was a risk factor for 30-day mortality [64,65,66,67,68,69]. Heart failure was also demonstrated as a risk factor for post-operative complications including: pneumonia (p=0.003) [68]; renal insufficiency (p=0.40) [68]; myocardial infarction (p=0.50) [68]; AKI (plessthan0.05) [69]; extended length of stay (plessthan0.001) [68]; and readmission (plessthan0.001) [68]. 

Heart failure and high-risk surgeries:

Heart failure is associated with significant morbidity and mortality in patients undergoing major non-cardiac surgery. This is despite advances in perioperative care [27]. Patients with heart failure suffer significantly worse outcomes than those patients with coronary artery disease alone [27].

Vascular:

Whilst there is limited evidence that cardiac testing prior to open abdominal aortic aneurysm (AAA) repair may not improve surgical outcomes in patients, large prospective studies suggest that heart failure is an independent risk factor for post-operative mortality (plessthan0.001) [60,64,70]. Pre-operative heart failure is also associated with post-operative mortality in open thoracic aortic aneurysm (TAA) repair (OR 1.85 95percentage CI 1.09-3.15 p=0.03) [71]. As well as mortality, patients with heart failure suffer increased morbidity, as post-operative major adverse cardiac events after emergency and elective open AAA repair, as well as conversion to open AAA repair from EVAR [56,70,72]. Heart failure has also been shown to be associated with post-operative 30-day readmission (plessthan0.05) [65,73] and increased length inpatient stay (plessthan0.001) [64]. The degree of heart failure, and LVEF, may be proportionate to post-operative morbidity and mortality [70].

Heart failure has also been shown to impact on 30-day outcomes of lower extremity revascularisation. In a large, prospective multi-centre study, patients with heart failure are more likely to suffer post-operative complication rates such as return to the operating theatre (p=0.022), prolonged intubation (p=0.011), reintubation (p=0.014), pneumonia (p=0.014), sepsis (p=0.011), extended inpatient stay (p=0.0001) and mortality (plessthan0.0001) [74]. Subsequent below knee or above knee amputation is associated with increased mortality in patients with heart failure (OR 1.10) [75]. Unfortunately, pre-operative identification of cardiac risk scores does not appear to improve outcomes for diabetic patients undergoing lower extremity revascularisation [76]. Large multi-centre studies have demonstrated that patients with heart failure undergoing infrainguinal bypass are at increased risk of mortality (plessthan0.025) [75,77]. 

Weakness of Evidence:

Patients with heart failure are likely to suffer additional co-morbidities and it is difficult to ascertain the impact of heart failure on post-operative outcomes alone. Additionally, certain combinations of different co-morbidities may be associated with worse outcomes. The term “heart failure” encompasses a wide spectrum of disease, and undoubtedly certain individuals included in this study will suffer more severe disease than others. Different studies have used different definitions of heart failure (grades of NYHA) and different end points. Additionally, immediacy and pre-operative optimisation will impact outcomes. The purpose of this study however was to perform a general assessment and whilst acknowledging these limitations, demonstrating an overarching trend in the existing evidence. 

Conclusion:

Heart failure is a major risk factor for morbidity and mortality in patients undergoing non-cardiac surgery. Morbidity and mortality appear to be consistent from low to high-risk operations. Heart failure is not binary, but exists on a disease spectrum. Operative risk is therefore a combination of factors including: urgency of surgery; degree of heart failure and opportunity for pre-operative optimisation; additional patient co-morbidities; and intraoperative course including blood loss and fluid shifts. Unfortunately, despite preoperative optimisation, patients with heart failure still suffer higher operative risk than those patients without heart failure. Additionally, current guidelines and risk scores classify heart failure as a binary outcome, and do not account for the breadth of disease under this single label.

Funding:

No funding was received for the review.

Authors’ Contributions:

LC: data collection; data analysis and interpretation; drafting article; approval of final version.

DB: study design; data collection; data analysis and interpretation; revising article; approval of final version.

Acknowledgements:

None

Conflict of Interest:

Nil.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann