Outcomes of HCM Patients Undergoing Noncardiac Surgery

Study Questions:

What are the perioperative outcomes of patients with hypertrophic cardiomyopathy (HCM) undergoing noncardiac surgery compared with a matched group of patients without HCM?

Methods:

This observational cohort study conducted at a tertiary care center included patients with HCM (n = 92, age 67 years, 54% men) undergoing intermediate-risk and high-risk noncardiac surgeries between January 2007 and December 2013 (excluding those <18 years, prior septal myectomy/alcohol ablation, low-risk surgery) who were 1:2 matched (based on age, gender, type and time of noncardiac surgery) with patients without HCM (n = 184, median age 65 years, 53% men). A composite endpoint (30-day postoperative death, myocardial infarction [MI], stroke, in-hospital decompensated congestive heart failure [CHF], and rehospitalization within 30 days) and postoperative atrial fibrillation were recorded. To determine the association between relevant predictors and 30-day composite events, univariable and multivariable logistic regression analyses were performed.

Results:

There was a significantly lower incidence of intraoperative hypotension/tachycardia in patients with HCM versus those without HCM (p < 0.001). At 30 days postoperatively, 42 (15%) patients had composite events. Rates of 30-day death, MI, or stroke were very low in patients with HCM (5%). However, a significantly higher proportion of patients with HCM met the composite endpoint versus patients without HCM (20 [22%] vs. 22 [12%], p = 0.03), driven by decompensated CHF. On logistic regression, HCM, high-risk noncardiac surgery, high anesthesia risk score, and intraoperative duration of hypotension were independently associated with 30-day composite events (p < 0.05).

Conclusions:

The authors concluded that patients with HCM undergoing high-risk and intermediate-risk noncardiac surgeries have a low perioperative event rate, at an experienced center.

Perspective:

This study reports that patients with HCM undergoing noncardiac surgery at an experienced center have a very low rate of hard perioperative events such as death, MI, or stroke. However, they have a significantly higher rate of 30-day composite events when compared with a matched cohort of patients without HCM undergoing noncardiac surgery. In addition to the standard perioperative risk, it appears that intraoperative hemodynamic shifts appear to play a major role in the occurrence of these events. During intraoperative management of HCM cases, particular attention must be paid to minimizing hemodynamic shifts, including at the time of anesthesia induction, to ensure good perioperative outcomes.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Anesthesia, Atrial Fibrillation, Cardiomyopathy, Hypertrophic, Heart Failure, Hemodynamics, Hypotension, Myocardial Infarction, Stroke, Surgical Procedures, Operative, Tachycardia, Tertiary Care Centers


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