info@auctorespublishing.com
+1-(302)-520-2644
+1-(302)-520-2644

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

  1. Home
  2. Journals
  3. Journal of Clinical Surgery and Research
  4. Archives
Submit Guidelines

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.

References

  1. Steen Dalby Kristensen, Juhani Knuuti, Antti Sarasteet. (2014). ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). European Heart Journal, Volume 35, Issue 35, 14 Pages 2383–2431.
    View at Publisher | View at Google Scholar
  2. Mosterd A, Hoes AW. (2007). Clinical epidemiology of heart failure. Heart;93: 1137 – 1146.
    View at Publisher | View at Google Scholar
  3. Large S. (2007). Surgery for heart failure. Heart. 93(3):392-402.
    View at Publisher | View at Google Scholar
  4. Hunt SA, Baker DW, Chin MH (2001). American College of Cardiology/American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 38(7):2101-2113.
    View at Publisher | View at Google Scholar
  5. Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, (1994). New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins.
    View at Publisher | View at Google Scholar
  6. Lerman BJ, Popat RA, Assimes TL. (2019). Association Between Heart Failure and Postoperative Mortality Among Patients Undergoing Ambulatory Noncardiac Surgery. JAMA Surg 154(10):907–914.
    View at Publisher | View at Google Scholar
  7. Faxén UL, Hallqvist L, Benson L, (2020). Heart Failure in Patients Undergoing Elective and Emergency Noncardiac Surgery: Still a Poorly Addressed Risk Factor. J Card Fail. (12):1034-1042.
    View at Publisher | View at Google Scholar
  8. Hammill BG, Curtis LH, Bennett-Guerrero E, et al. (2008). Impact of heart failure on patients undergoing major noncardiac surgery. Anaesthesiology. 108(4):559-567.
    View at Publisher | View at Google Scholar
  9. Smilowitz NR, Banco D, Katz SD, et al. (2021). Association between heart failure and perioperative outcomes in patients undergoing non-cardiac surgery. Eur Heart J Qual Care Clin Outcomes. 25;7(1):68-75.
    View at Publisher | View at Google Scholar
  10. Moodley Y, Biccard BM. (2015). Predictors of in-hospital mortality following non-cardiac surgery: Findings from an analysis of a South African hospital administrative database. S Afr Med J. 105(2):126-129.
    View at Publisher | View at Google Scholar
  11. Mattingly AS, Lerman BJ, Popat R, Wren SM. (2019). Association of Sex with Postoperative Mortality Among Patients with Heart Failure Who Underwent Elective Noncardiac Operations. JAMA Netw Open. 2(11): e1914420.
    View at Publisher | View at Google Scholar
  12. Lerman BJ, Popat RA, Assimes TL, et al. (2019). Association of Left Ventricular Ejection Fraction and Symptoms with Mortality After Elective Noncardiac Surgery Among Patients with Heart Failure. JAMA. 12;321(6):572-579.
    View at Publisher | View at Google Scholar
  13. Healy KO, Waksmonski CA, Altman RK, et al. (2010). Perioperative outcome and long-term mortality for heart failure patients undergoing intermediate- and high-risk noncardiac surgery: impact of left ventricular ejection fraction. Congest Heart Fail. 16(2):45-49.
    View at Publisher | View at Google Scholar
  14. Faxén UL, Hallqvist L, Benson L et al. (2020). Heart Failure in Patients Undergoing Elective and Emergency Noncardiac Surgery: Still a Poorly Addressed Risk Factor. J Card Fail. 26(12):1034-1042.
    View at Publisher | View at Google Scholar
  15. Patel AY, Eagle KA, Vaishnava P. (2015). Cardiac risk of noncardiac surgery. J Am Coll Cardiol. 66(19):2140-2148.
    View at Publisher | View at Google Scholar
  16. Damen J, Hagemeijer JW, van den Broek L, Poldermans D; (2008). CBO-werkgroep Preventie Perioperatieve Cardiale Complicaties bij Niet-cardiale Chirurgie. De preventie van perioperatieve cardiale complicaties bij niet-cardiale chirurgie: een evidence-based richtlijn [Prevention of perioperative cardiac complications in non-cardiac surgery: an evidence-based guideline]. Ned Tijdschr Geneeskd. 152(48):2612-2616.
    View at Publisher | View at Google Scholar
  17. Aresti NA, Malik AA, Ihsan KM, et al. (2014). Perioperative management of cardiac disease. J Perioper Pract. 24(1-2):9-14.
    View at Publisher | View at Google Scholar
  18. Goldman L, Caldera DL, Southwick FS, et al. (1978). Cardiac risk factors and complications in non-cardiac surgery. Medicine (Baltimore). 57(4):357-370.
    View at Publisher | View at Google Scholar
  19. Bolat İ. (2020). Preoperative Right Ventricular Echocardiographic Parameters Predict Perioperative Cardiovascular Complications in Patients Undergoing Non-Cardiac Surgery. Heart Lung Circ. 29(8):1146-1151.
    View at Publisher | View at Google Scholar
  20. Sabaté S, Mases A, Guilera N, et al. (2011). ANESCARDIOCAT Group. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth. 107(6):879-890.
    View at Publisher | View at Google Scholar
  21. Lerman BJ, Popat RA, Assimes TL, Heidenreich PA, Wren SM. et al. (2019). Association of Left Ventricular Ejection Fraction and Symptoms with Mortality After Elective Noncardiac Surgery Among Patients with Heart Failure. JAMA. 321(6):572-579.
    View at Publisher | View at Google Scholar
  22. Healy KO, Waksmonski CA, Altman RK, Stetson PD, Reyentovich A, et al. (2010). Perioperative outcome and long-term mortality for heart failure patients undergoing intermediate- and high-risk noncardiac surgery: impact of left ventricular ejection fraction. Congest Heart Fail. 16(2):45-49.
    View at Publisher | View at Google Scholar
  23. Lo PH, Chang CC, Yeh CC, et al. (2021). Adverse Outcomes after Non-Cardiac Surgeries in Patients with Heart Failure: A Propensity-Score Matched Study. J Clin Med. 10(7):1501.
    View at Publisher | View at Google Scholar
  24. Maile MD, Engoren MC, Tremper KK, et al. (2014). Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg. 119(3):522-532.
    View at Publisher | View at Google Scholar
  25. Meyer TE. (2022). Perioperative management of heart failure in patients undergoing noncardiac surgery. Ted W Post, Waltham MA.
    View at Publisher | View at Google Scholar
  26. van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. (2011). Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. Circulation. 124(3):289-296.
    View at Publisher | View at Google Scholar
  27. Hernandez AF, Whellan DJ, Stroud S, et al. (2004). Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 44(7):1446-1453.
    View at Publisher | View at Google Scholar
  28. Goldfarb M, Perry Z, A Hodin R, Parangi S. (2011). Medical and surgical risks in thyroid surgery: lessons from the NSQIP. Ann Surg Oncol. 18(13):3551-3558.
    View at Publisher | View at Google Scholar
  29. Wu TY, Akopian G, Katz SG. (2014). Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis. Am J Surg. 1069-1073.
    View at Publisher | View at Google Scholar
  30. Goldstein LB, Samsa GP, Matchar DB, Oddone EZ. (1998). Multicenter review of preoperative risk factors for endarterectomy for asymptomatic carotid artery stenosis. Stroke. 29(4):750-753.
    View at Publisher | View at Google Scholar
  31. Calvillo-King L, Xuan L, Zhang S, et al. (2010). Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: derivation and validation of a clinical risk score. Stroke. 41(12):2786-2794.
    View at Publisher | View at Google Scholar
  32. Dua A, Romanelli M, Upchurch GR Jr, Pan J, Hood D, Hodgson KJ, et al. (2016). Predictors of poor outcome after carotid intervention. J Vasc Surg. 64(3):663-670.
    View at Publisher | View at Google Scholar
  33. Squizzato F, Antonello M, Taglialavoro et al. (2020). Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients. Eur J Vasc Endovasc Surg. 59(4):536-544.
    View at Publisher | View at Google Scholar
  34. Khorgami Z, Hui BY, Mushtaq N et al. (2019). Predictors of mortality after elective ventral hernia repair: an analysis of national inpatient sample. Hernia. 979-985.
    View at Publisher | View at Google Scholar
  35. Kaoutzanis C, Leichtle SW, Mouawad NJ, et al. (2015). Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair. Hernia. 19(1):113-123.
    View at Publisher | View at Google Scholar
  36. Pallati PK, Gupta PK, Bichala S et al. (2013). Short-term outcomes of inguinal hernia repair in octogenarians and nonagenarians. Hernia. 17(6):723-727.
    View at Publisher | View at Google Scholar
  37. Marco-Martínez J, Elola-Somoza FJ, Fernández-Pérez C, et al. (2021 ). Heart Failure Is a Poor Prognosis Risk Factor in Patients Undergoing Cholecystectomy: Results from a Spanish Data-Based Analysis. J Clin Med. 10(8):1731.
    View at Publisher | View at Google Scholar
  38. Hall CM, Jupiter DC, Regner JL. (2016). Newly diagnosed and decompensated congestive heart failure is associated with increased rates of pneumonia, reintubation, and death following laparoscopic cholecystectomy: A NSQIP database review of 143,761 patients. Int J Surg. 35:209-213.
    View at Publisher | View at Google Scholar
  39. Hall CM, Jupiter DC, Regner JL. (2016). Newly diagnosed and decompensated congestive heart failure is associated with increased rates of pneumonia, reintubation, and death following laparoscopic cholecystectomy: A NSQIP database review of 143,761 patients. Int J Surg. 35:209-213.
    View at Publisher | View at Google Scholar
  40. Boehme J, McKinley S, Michael Brunt L, et al. (2016). Patient comorbidities increase postoperative resource utilization after laparoscopic and open cholecystectomy. Surg Endosc. 30(6):2217-2230.
    View at Publisher | View at Google Scholar
  41. Kirchhoff P, Matz D, Dincler S, Buchmann P. (2011). Predictive risk factors for intra- and postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis: a multivariate analysis. World J Surg. 35(3):677-683.
    View at Publisher | View at Google Scholar
  42. Haskins IN, Amdur R, Sarani B, Vaziri K. (2015). Congestive heart failure is a risk factor for venous thromboembolism in bariatric surgery. Surg Obes Relat Dis. 11(5):1140-1145.
    View at Publisher | View at Google Scholar
  43. Sheer AJ, Heckman JE, Schneider EB, Wu AW, Segal JB, et al. (2011). Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery. Dis Colon Rectum. 54(11):1430-1437.
    View at Publisher | View at Google Scholar
  44. Piessen G, Muscari F, Rivkine E, Sbaï-Idrissi MS, Lorimier G, et al. ( 2011). FRENCH (Fédération de Recherche EN CHirurgie). Prevalence of and risk factors for morbidity after elective left colectomy: cancer vs noncomplicated diverticular disease. Arch Surg. 146(10):1149-1155.
    View at Publisher | View at Google Scholar
  45. Aga E, Keinan-Boker L, Eithan A, et al. (2015). Surgical site infections after abdominal surgery: incidence and risk factors. A prospective cohort studies. Infect Dis (Lond). 47(11):761-767.
    View at Publisher | View at Google Scholar
  46. Arhinful E, Jenkins D, Schiller HJ, Cullinane DC, Smoot DL, (2011 ). Outcomes of damage control laparotomy with open abdomen management in the octogenarian population. J Trauma. 70(3):616-621.
    View at Publisher | View at Google Scholar
  47. Bertges DJ, Neal D, Schanzer A et al. (2016). Vascular Quality Initiative. The Vascular Quality Initiative Cardiac Risk Index for prediction of myocardial infarction after vascular surgery. J Vasc Surg. 64(5):1411-1421.
    View at Publisher | View at Google Scholar
  48. Beaulieu RJ, Sutzko DC, Albright J, Jeruzal E, Osborne NH, et al. (2020). Association of High Mortality with Postoperative Myocardial Infarction After Major Vascular Surgery Despite Use of Evidence-Based Therapies. JAMA Surg. 155(2):131-137.
    View at Publisher | View at Google Scholar
  49. Columbo JA, Barnes JA, Jones DW, et al. (2020). Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing. J Vasc Surg. 72(5):1584-1592.
    View at Publisher | View at Google Scholar
  50. Moussa Pacha H, Mir T, Al-Khadra Y, et al. (2021). Trends and causes of readmission following peripheral vascular intervention in patients with peripheral vascular disease. Catheter Cardiovasc Interv 98(3):540-548.
    View at Publisher | View at Google Scholar
  51. Bodewes TC, Soden PA, Ultee KH et al. (2017). Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions. J Vasc Surg. 65(2):484-494.
    View at Publisher | View at Google Scholar
  52. Sousa J, Rocha-Neves J, Oliveira-Pinto J, Mansilha A. (2021). Myocardial injury after non-cardiac surgery (MINS) in EVAR patients: a retrospective single-centered study. J Cardiovasc Surg (Torino). 62(2):130-135.
    View at Publisher | View at Google Scholar
  53. Noori VJ, Healey CT, Eldrup-Jorgensen J, et al. (2019). Vascular Study Group of New England. Comparison of major adverse event rates after elective endovascular aneurysm repair in New England using a novel measure of complication severity. J Vasc Surg. 70(1):74-79.
    View at Publisher | View at Google Scholar
  54. Nejim B, Zarkowsky D, Hicks CW, et al. (2019). Predictors of in-hospital adverse events after endovascular aortic aneurysm repair. J Vasc Surg. 70(1):80-91.
    View at Publisher | View at Google Scholar
  55. Bostock IC, Zarkowsky DS, Hicks CW, et al. (2018). Outcomes and Risk Factors Associated with Prolonged Intubation after EVAR. Ann Vasc Surg. 50:167-172.
    View at Publisher | View at Google Scholar
  56. de Virgilio C, Bui H, Donayre C, et al. (1999). Endovascular vs opens abdominal aortic aneurysm repair: a comparison of cardiac morbidity and mortality. Arch Surg. 134(9):947-50; discussion 950-951.
    View at Publisher | View at Google Scholar
  57. King EG, Farber A, Rybin D, et al. (2017). Preoperative Risk Factors Predict Protracted Hospital Length of Stay after Elective Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg. 43:73-78.
    View at Publisher | View at Google Scholar
  58. Chen SL, Kuo IJ, Kabutey NK et al. (2018). Perioperative risk factors for hospital readmission after elective endovascular aortic aneurysm repair. J Vasc Surg. 68(3):731-738.
    View at Publisher | View at Google Scholar
  59. Dua A, Rothenberg KA, Wohlaer M et al. (2019). Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database. J Vasc Surg. 70(5):1603-1611.
    View at Publisher | View at Google Scholar
  60. Giles KA, Schermerhorn ML, O'Malley AJ et al. (2009). Risk prediction for perioperative mortality of endovascular vs open repair of abdominal aortic aneurysms using the Medicare population. J Vasc Surg. 50(2):256-262.
    View at Publisher | View at Google Scholar
  61. Gupta PK, Engelbert TL, Ramanan B, et al. (2014). Postdischarge outcomes after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 59(4):903-908.
    View at Publisher | View at Google Scholar
  62. Chang H, Rockman CB, Jacobowitz GR, et al. (2021). Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair. J Vasc Surg. 73(5):1583-1592.
    View at Publisher | View at Google Scholar
  63. Ramirez JL, Zarkowsky DS, Boitano LT, et al. (2021). A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair. J Vasc Surg. 73(5):1549-1556.
    View at Publisher | View at Google Scholar
  64. Sanders RD, Bottle A, Jameson SS, Mozid A, Aylin P, et al. (2012). Walters M, Lees KR, Maze M. Independent preoperative predictors of outcomes in orthopedic and vascular surgery: the influence of time interval between an acute coronary syndrome or stroke and the operation. Ann Surg. 255(5):901-907.
    View at Publisher | View at Google Scholar
  65. Cha YH, Ha YC, Ryu HJ, et al. (2020). Effect of heart failure on postoperative short and long-term mortality in elderly patients with hip fracture. Injury. 51(3):694-698.
    View at Publisher | View at Google Scholar
  66. Sanz-Reig J, Salvador Marín J, Ferrández Martínez J, et al. (2018). Prognostic factors and predictive model for in-hospital mortality following hip fractures in the elderly. Chin J Traumatol. 21(3):163-169.
    View at Publisher | View at Google Scholar
  67. Fansa A, Huff S, Ebraheim N. (2016). Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures. Clin Orthop Surg. 8(2):140-145.
    View at Publisher | View at Google Scholar
  68. Lee R, Lee D, Gowda NB, et al. (2019). Surgical complications associated with congestive heart failure in elderly patients following primary hip hemiarthroplasty for femoral neck fractures. Eur J Orthop Surg Traumatol. 29(6):1253-1261.
    View at Publisher | View at Google Scholar
  69. Cho W, Hwang TY, Choi YK, et al. (2019). Diastolic dysfunction and acute kidney injury in elderly patients with femoral neck fracture. Kidney Res Clin Pract. 31;38(1):33-41.
    View at Publisher | View at Google Scholar
  70. Fletcher JP, Antico VF, Gruenewald S, Kershaw LZ. (1989). Risk of aortic aneurysm surgery as assessed by preoperative gated heart pool scan. Br J Surg. 76(1):26-28.
    View at Publisher | View at Google Scholar
  71. Suzuki S, Davis CA 3rd, Miller CC 3rd, Huynh TT, Estrera AL, et al. (2003). Cardiac function predicts mortality following thoracoabdominal and descending thoracic aortic aneurysm repair. Eur J Cardiothorac Surg. 24(1):119-124.
    View at Publisher | View at Google Scholar
  72. Scali ST, Runge SJ, Feezor RJ, Giles KA, Fatima J,et al.(2016). Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 64(2):338-347.
    View at Publisher | View at Google Scholar
  73. Dakour Aridi HN, Locham S, Nejim B, Ghajar NS, Alshaikh H, et al. (2018). Indications, risk factors, and outcomes of 30-day readmission after infrarenal abdominal aneurysm repair. J Vasc Surg. 67(3):747-758.
    View at Publisher | View at Google Scholar
  74. Amdur RL, Ashby B, Neville R, Tunstall A, Nguyen BN, et al. (2016). The effect of congestive heart failure on perioperative outcomes in patients undergoing lower extremity revascularization. J Vasc Surg. 63(5):1289-1295.
    View at Publisher | View at Google Scholar
  75. Miyata T, Mii S, Kumamaru H, Takahashi A, Miyata H; (2021). Japanese Society for Vascular Surgery JAPAN Critical Limb Ischemia Database (JCLIMB) Committee. Risk prediction model for early outcomes of revascularization for chronic limb-threatening ischaemia. Br J Surg. 108(8):941-950.
    View at Publisher | View at Google Scholar
  76. Monahan TS, Shrikhande GV, Pomposelli FB et al. (2005). Preoperative cardiac evaluation does not improve or predict perioperative or late survival in asymptomatic diabetic patients undergoing elective infrainguinal arterial reconstruction. J Vasc Surg. 41(1):38-45.
    View at Publisher | View at Google Scholar
  77. Dinga Madou I, Slade MD, Orion KC, Sarac T, Ochoa Chaar CI. (2017). The Impact of Functional Status on the Outcomes of Endovascular Lower Extremity Revascularization for Critical Limb Ischemia in the Elderly. Ann Vasc Surg. 45:42-48.
    View at Publisher | View at Google Scholar

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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¨.

img

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.

img

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!”

img

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

img

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.

img

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.

img

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.

img

Luiz Sellmann

I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.

img

Zhao Jia