Should a patient with a moderately reduced left ventricular ejection fraction and signs of heart failure be sent to surgery immediately?

Should This Patient Be Sent to Surgery Immediately?

No, this patient should not be sent to surgery immediately for the valvular disease alone, but requires urgent medical optimization and careful risk stratification before any elective noncardiac surgery. If cardiac valve surgery is being considered, the moderate mitral regurgitation with moderately reduced LVEF (40-45%) does not meet threshold criteria for urgent valve intervention.

Key Clinical Context

This patient presents with:

• Moderately reduced LVEF (40-45%) - this is heart failure with reduced ejection fraction (HFrEF) 1
• Moderate functional mitral regurgitation - likely secondary to LV dysfunction 2
• Biventricular dysfunction with RV enlargement and reduced RV function 2
• Biatrial enlargement suggesting chronic volume overload 2
• Mild-moderate tricuspid regurgitation - often functional from RV dysfunction 2

If Considering Noncardiac Surgery

Preoperative Cardiac Evaluation

The ACC/AHA perioperative guidelines are clear that preoperative surgical correction of mitral valve disease is NOT indicated before noncardiac surgery unless the valvular condition should be corrected to prolong survival independent of the proposed surgery 2.

• Patients with moderately reduced LVEF (40-45%) have significantly increased perioperative risk, with LVEF <30% associated with the highest mortality 2, 3
• This patient's LVEF of 40-45% places them in an intermediate-risk category 2
• Preoperative evaluation of LV function is reasonable for patients with current heart failure and worsening dyspnea (Class IIa recommendation) 2

Medical Optimization Required

Before any elective noncardiac surgery, this patient requires:

• Afterload reduction and diuretics to achieve maximal hemodynamic stabilization before high-risk surgery 2
• Heart rate control is critical, especially given the functional mitral regurgitation 2
• Optimization of guideline-directed medical therapy for HFrEF including beta-blockers, ACE inhibitors/ARBs, and mineralocorticoid receptor antagonists 1
• Assessment for signs of decompensated heart failure that would require stabilization 2

Risk Stratification

Even mild reduction of LVEF in patients with mitral regurgitation may be a sign of reduced ventricular reserve, as LVEF may overestimate true LV performance in the setting of MR 2, 4.

• The combination of biventricular dysfunction, biatrial enlargement, and moderate MR suggests advanced cardiac disease 2
• Perioperative risk of heart failure exacerbation is approximately 25% in patients with chronic heart failure 3
• LVEF <30% is associated with significant increase in perioperative mortality and myocardial infarction 3

If Considering Cardiac Valve Surgery

Mitral Regurgitation Surgery Indications

This patient does NOT meet criteria for urgent mitral valve surgery based on current guidelines:

The ESC/EACTS and ACC/AHA guidelines indicate surgery for severe primary mitral regurgitation when 2:

• LVEF ≤60% and/or LVESD ≥45 mm (Class I indication)
• Symptomatic patients with LVEF >30% (Class I indication)

This patient has:

• Moderate (not severe) MR - does not meet severity threshold 2
• Functional (not primary) MR - likely secondary to LV dysfunction 2
• LVEF 40-45% - above the critical 30% threshold but concerning 2

Important Caveats for Functional MR

Functional mitral regurgitation is managed differently than primary (organic) MR:

• Medical therapy with afterload reduction is the primary approach for functional MR with heart failure 2
• Surgery for functional MR is generally reserved for severe MR with persistent symptoms despite optimal medical therapy 2
• The moderate severity in this case suggests medical optimization should be attempted first 2

Clinical Pitfalls to Avoid

Common Errors

• Do not assume "normal" LVEF in MR - LVEF may appear preserved due to reduced afterload from regurgitation, masking true myocardial dysfunction 4
• Do not rush to surgery for moderate functional MR - this is typically managed medically unless severe and symptomatic despite optimal therapy 2
• Do not proceed with elective noncardiac surgery without medical optimization - patients with HFrEF require careful preoperative preparation 2

Critical Assessment Points

• Determine if symptoms are present - dyspnea, exercise intolerance, or signs of heart failure decompensation 2, 4
• Assess severity of MR accurately - moderate vs severe makes a critical difference in management 2
• Evaluate for ischemic etiology - functional MR from post-infarction remodeling has different implications 2
• Consider RV dysfunction impact - the enlarged RV with reduced function adds significant risk 2

Recommended Management Pathway

Immediate Steps

• Optimize medical therapy for heart failure with beta-blockers, ACE inhibitors/ARBs, diuretics, and consider mineralocorticoid receptor antagonists 1
• Assess volume status and achieve euvolemia with diuretics 2
• Control heart rate to optimize diastolic filling time 2
• Evaluate for symptoms including dyspnea, exercise intolerance, or orthopnea 2, 4

Follow-up Evaluation

• Repeat echocardiography in 3-6 months after medical optimization to reassess LV function and MR severity 2
• Monitor for recovery of LVEF - some patients with HFrEF show improvement with optimal medical therapy 5, 6
• Serial assessment of functional capacity to guide timing of any intervention 2

Surgery Timing (If Needed)

• Defer elective noncardiac surgery until cardiac status is optimized 2
• Consider cardiac valve surgery only if MR progresses to severe with symptoms or further LV deterioration despite medical therapy 2
• If valve surgery becomes indicated, mitral valve repair is strongly preferred over replacement when feasible 2