Effect of Ischemic Cardiomyopathy on Perioperative Mortality after Endovascular Abdominal Aortic Aneurysm Repair

One in five patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) will have left ventricular dysfunction. Yet, little is known about the perioperative risks of the different types of cardiomyopathy. We compared the outcomes of patients with ischemic cardiomyopathy (ICM) undergoing EVAR with those of patients with non-ICM (NICM). Patients with left ventricular dysfunction (ejection fraction [EF] <50%) in the Vascular Quality Initiative database undergoing elective EVAR were identified. The patients were categorized as having ICM if they had a history of myocardial infarction, coronary artery bypass graft, or percutaneous coronary intervention. The remaining patients were considered to have NICM. The patient characteristics and outcomes were compared. Multivariable regression was performed to assess for factors independently associated with perioperative mortality. A total of 5910 patients had a low EF (<50%), of whom 4202 (71.1%) had ICM and 1708 (28.9%) NICM. Patients with ICM were more likely to have hypertension, diabetes, congestive heart failure, and an EF <30% and to be white and were less likely to be active smokers (Table I). A univariate comparison of the outcomes revealed no differences in complication rates or total morbidity. Perioperative mortality was significantly greater in the ICM group than in the NICM group (1.9% vs 1.1%; P = .024). After a mean follow-up of 430 ± 254 days, no difference was found in mortality between the two groups (18.1% vs 17.3%; P = .471). On multivariable regression, ischemic cardiomyopathy (odds ratio, 1.82; 95% confidence interval, 1.09-3.05), female gender, diabetes, and age were independently associated with increased perioperative mortality (Table II). ICM is associated with a significant increase in perioperative mortality after EVAR. Distinguishing between different cardiomyopathy types in patients with a low EF is important for perioperative risk assessment in patients undergoing EVAR.Table 1Univariate comparison of baseline characteristics of NICM vs ICM patients undergoing elective EVARCharacteristicNICM (n = 1708)ICM (n = 4202)P valueAge, years73.82 ± 9.2873.55 ± 8.53.283Female gender269 (15.75)378 (9)<.001Race<.001 White1490 (87.24)3830 (91.15) African American149 (8.72)207 (4.93) Other69 (4.04)165 (3.93)BMI group, kg/m2.017 <1840 (2.34)72 (1.71) 18-24.9538 (31.5)1181 (28.11) 25-34.9945 (55.33)2469 (58.76) >35185 (10.83)480 (11.42)Mean BMI, kg/m227.74 ± 6.1228.09 ± 5.64.036Transferred from facility61 (3.57)142 (3.38).706Dependent functional status587 (34.37)1522 (36.22).178Comorbidity Current smoker565 (33.08)1173 (27.92)<.001 Hypertension1376 (80.56)3650 (86.86)<.001 Diabetes265 (15.52)918 (21.85)<.001 Congestive heart failure533 (31.21)1862 (44.31)<.001 COPD632 (37)1583 (37.67).629 ASA class ≥IV144 (8.43)512 (12.18)<.001 Prior AAA repair35 (2.05)75 (1.78).496 Prior non-AAA repair13 (0.76)44 (1.05).308Preoperative aspirin1038 (60.77)3349 (79.7)<.001Preoperative statin1137 (66.57)3596 (85.58)<.001Preoperative antiplatelet (P2Y12 inhibitor)155 (9.07)1200 (28.56)<.001Preoperative anticoagulation571 (33.43)1386 (32.98).741Aneurysm diameter, mm56.69 ± 11.6456.73 ± 11.01.905EF <30%240 (14.05)785 (18.68)<.001AAA, Abdominal aortic aneurysm; ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; EF, ejection fraction; ICM, ischemic cardiomyopathy; NICM, nonischemic cardiomyopathy.Data presented as mean ± standard deviation or number (%).Boldface P values represent statistical significance. Open table in a new tab Table IIMultivariable analysis of ischemic cardiomyopathy as a risk factor for 30-day mortalityVariableOR95% CIICM vs NICM1.821.09-3.05Age1.051.03-1.08Female gender2.051.25-3.39African American vs white race1.040.44-2.43Other vs white race1.750.79-3.86BMI0.980.94-1.02Dependent functional status1.290.86-1.93Current smoker1.270.79-2.04Hypertension1.180.72-1.94Diabetes2.051.32-3.16History of CHF1.270.84-1.92Preoperative EF <30%0.960.57-1.63BMI, body mass index; CHF, congestive heart failure; CI, confidence interval; EF, ejection fraction; ICM, ischemic cardiomyopathy; NICM, nonischemic cardiomyopathy; OR, odds ratio.Boldface values indicate statistical significance. Open table in a new tab