What are the anesthetic considerations for patients with reduced ejection fraction (REF) heart failure undergoing surgery?

Anesthetic Considerations for Reduced Ejection Fraction Heart Failure

Patients with reduced ejection fraction heart failure require careful perioperative management with invasive hemodynamic monitoring, maintenance of preload, avoidance of myocardial depressants, and judicious use of vasopressors to optimize outcomes. Heart failure with reduced ejection fraction (HFrEF) significantly increases perioperative risk, with mortality rates up to 8.34% at 90 days for patients with ejection fractions <25% 1.

Preoperative Assessment and Optimization

• Risk stratification: HFrEF patients have 2.35 times higher adjusted odds of 90-day mortality compared to those without heart failure 1
• Medication management:
  • Continue guideline-directed medical therapy (GDMT) including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists up to surgery 1
  • Consider postponing elective surgery in patients with decompensated heart failure for medical optimization 1
  • For patients on SGLT2 inhibitors, consider discontinuation 3-4 days before surgery to reduce perioperative complications 1

Intraoperative Monitoring

• Invasive arterial monitoring: Essential for beat-to-beat blood pressure monitoring and arterial blood sampling
• Central venous access: For administration of vasoactive medications and assessment of volume status
• Pulmonary artery catheter: Consider in patients with severe HFrEF (EF <30%) for direct measurement of cardiac filling pressures, cardiac output, and mixed venous oxygen saturation 1
• Transesophageal echocardiography (TEE): Valuable for real-time assessment of ventricular function, volume status, and response to interventions 1

Anesthetic Technique Selection

• Regional anesthesia: Consider selective spinal or epidural techniques for appropriate surgeries to minimize myocardial depression 2
• General anesthesia: When required, use a balanced approach with careful titration of anesthetic agents
  • Induction agents:
    • Etomidate preferred due to cardiovascular stability 3
    • Avoid high doses of propofol due to myocardial depression and vasodilation
  • Maintenance:
    • Volatile agents at low concentrations (0.5-0.7 MAC) to minimize myocardial depression
    • Consider opioid-based techniques for hemodynamic stability
    • Caution with remifentanil: Associated with increased complications in HFrEF patients (OR 3.13) 3

Hemodynamic Management

• Preload optimization:

  • Maintain adequate intravascular volume without overload
  • Use dynamic parameters (pulse pressure variation, stroke volume variation) to guide fluid therapy 4
  • Target euvolemia; avoid both hypovolemia and hypervolemia

• Contractility management:

  • Inotropic support: Consider for patients with signs of low cardiac output
    • Dobutamine: First-line inotrope for short-term support
    • Milrinone: Alternative for patients on beta-blockers
    • Levosimendan: Consider for patients with EF <40% undergoing major surgery; infusion at 0.1 μg/kg/min for 24 hours without loading dose 5

• Afterload management:

  • Vasopressors:
    • Phenylephrine or norepinephrine preferred for hypotension 1
    • Avoid pure vasodilators in hypotensive patients

Special Considerations

• Avoid factors that worsen heart failure:

  • Tachycardia: Reduces diastolic filling time and increases myocardial oxygen demand
  • Bradycardia: May reduce cardiac output in patients dependent on heart rate
  • Hypoxemia and hypercarbia: Can increase pulmonary vascular resistance
  • Acidosis: Reduces myocardial contractility and response to inotropes

• Arrhythmia management:

  • Maintain sinus rhythm when possible
  • Treat atrial fibrillation promptly, especially if associated with hemodynamic compromise 1
  • Have defibrillator immediately available

Postoperative Care

• Monitoring: Continue invasive monitoring into the postoperative period for high-risk patients
• Pain management: Multimodal analgesia to minimize opioid requirements and respiratory depression
• Medication resumption: Restart GDMT as soon as hemodynamically stable and oral intake is established 1
• Volume management: Continue careful fluid balance monitoring and diuresis as needed

Common Pitfalls to Avoid

1. Abrupt discontinuation of chronic heart failure medications: Can lead to rebound hypertension or decompensation
2. Excessive fluid administration: Can precipitate pulmonary edema
3. Inadequate monitoring: Failure to detect early signs of decompensation
4. Overreliance on vasopressors: May increase afterload excessively and worsen cardiac function
5. Inadequate pain control: Pain-induced sympathetic stimulation can increase myocardial oxygen demand

By carefully managing these considerations, anesthesiologists can optimize outcomes for patients with reduced ejection fraction heart failure undergoing surgery, reducing the risk of perioperative complications and mortality.