Is a patient with heart failure with reduced ejection fraction (HFrEF) fit for surgery?

Surgical Fitness Assessment for HFrEF Patients

A patient with HFrEF can proceed to surgery after preoperative optimization and risk stratification, with regional anesthesia strongly preferred over general anesthesia, and postoperative high-dependency monitoring for at least 24 hours. 1

Immediate Preoperative Assessment

Before determining surgical fitness, you must evaluate and correct the following reversible factors:

• Volume status optimization: Correct hypovolemia or fluid overload before proceeding 1
• Electrolyte correction: Normalize sodium and potassium levels, as abnormalities increase perioperative risk 1
• Hemoglobin optimization: Target >8 g/dL to reduce cardiac stress 1
• Arrhythmia control: Treat any ventricular rate >120/min before surgery 1
• Acute decompensation: If the patient is in acute decompensated heart failure, stabilize before elective surgery 1

Risk Stratification Based on Ejection Fraction

For EF <30%: These patients require advanced hemodynamic monitoring intraoperatively and are at highest risk 1. However, surgery is not contraindicated if optimized.

For EF 30-40%: Standard monitoring with careful fluid management is appropriate 1

The presence of HFrEF alone does not make a patient unfit for surgery, but the severity and optimization status determine perioperative approach 2.

Medication Optimization Before Surgery

Continue all guideline-directed medical therapy through the perioperative period 1:

• Beta-blockers should be continued to prevent withdrawal and arrhythmias 1
• SGLT2 inhibitors, MRAs, and ARNI/ACE inhibitors should be continued when possible 1, 3
• Only hold diuretics if volume depleted 1

Do not delay urgent surgery (such as femur fractures) for extensive medication titration—proceed with basic optimization 1.

Anesthetic Strategy: The Critical Decision

Regional anesthesia is strongly preferred over general anesthesia for patients with severe LV dysfunction 1. This is a Class I recommendation based on reduced myocardial depression and better hemodynamic stability.

For orthopedic procedures:

• Femur fractures: Use spinal or epidural anesthesia 1
• Upper extremity fractures: Use peripheral nerve blocks (brachial plexus) 1

If general anesthesia is unavoidable:

• Use agents with minimal myocardial depression 1
• Consider combined regional-general approach to minimize general anesthetic requirements 1

Intraoperative Management

For EF <30%: Advanced hemodynamic monitoring is mandatory 1:

• Cardiac output-guided fluid administration reduces hospital stay 1
• Avoid intravascular volume depletion 1
• Increase inspired oxygen concentration, especially during cemented procedures 1

Postoperative Care Requirements

All HFrEF patients require 1:

• High-dependency unit monitoring for at least 24 hours 1
• Supplemental oxygen for at least 24 hours 1
• Continuation of heart failure medications as appropriate 1

Specific Surgical Considerations

For cardiac surgery in HFrEF patients 2:

• CABG is reasonable for patients with EF <35% and significant CAD when viable myocardium is present 2
• Surgical aortic valve replacement is reasonable for critical aortic stenosis with predicted surgical mortality ≤10% 2
• TAVI is recommended for patients deemed inoperable by a heart team 2

Common Pitfalls to Avoid

Do not delay urgent surgery for complete medication optimization—basic stabilization is sufficient for urgent cases like fractures 1.

Do not discontinue beta-blockers perioperatively—this increases risk of arrhythmias and adverse events 1.

Do not assume low blood pressure contraindicates surgery—asymptomatic hypotension (SBP 80-100 mmHg) with adequate perfusion is acceptable in optimized HFrEF patients 2, 1.

Do not use general anesthesia when regional techniques are feasible—this significantly increases cardiac risk 1.

The Bottom Line Algorithm

1. Assess for acute decompensation: If present, stabilize first 1
2. Correct reversible factors: Electrolytes, volume status, hemoglobin, arrhythmias 1
3. Continue GDMT medications through perioperative period 1
4. Choose regional over general anesthesia whenever possible 1
5. Plan for advanced monitoring if EF <30% 1
6. Arrange high-dependency postoperative care for at least 24 hours 1

For urgent surgery (e.g., hip fracture), proceed after basic optimization rather than delaying for complete medical optimization 1.