The association of reduced ejection fraction with the outcomes of endovascular abdominal aortic aneurysm repair

Objective: It is estimated that 20% of patients undergoing elective abdominal aortic aneurysm repair suffer from cardiomyopathy. This study examines the impact of reduced ejection fraction (EF) on the outcomes of endovascular aneurysm repair (EVAR) and compares the different types of cardiomyopathies causing reduction of EF. Our hypothesis is that reduction in EF is associated with higher mortality after EVAR.

Methods: We examined the Vascular Quality Initiative database for EVAR from 2003 to 2020. Patients presenting with symptomatic abdominal aortic aneurysm or rupture were excluded. Patients were excluded if age, sex, mortality, and EF were not available. Patients were stratified into categories in two separate analyses. The first analysis examines differences between <30% EF, 30% to 50% EF, and EF >50%, and the second analysis examined differences between ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy in patients with reduced EF. Patients' demographics, comorbidities, operative characteristics, and outcomes were compared. Statistical comparisons were performed using χ² analysis for categorical variables and analysis of variance for continuous variables. Multivariable comparison was performed to find characteristics impacting mortality.

Results: There were 26,037 patients included and 20,127 (77.3%) had a normal EF (>50%), 4885 (18.7%) patients had a moderately reduced EF of 30% to 50%, and only 1025 (3.9%) patients had a severely reduced EF (<30%). The 30-day mortality was not significantly different between patients with very reduced (1.9%) and reduced EF (1.7%), but was significantly higher than patients with normal EF (0.8%) (P < .001). There was a nearly two-fold increase in 30-day mortality for ischemic cardiomyopathy (1.1% vs 2.0%; P = .024) compared with nonischemic cardiomyopathy, but there was no difference in long-term mortality between the two groups.

Conclusions: Elective EVAR in patients with reduced EF is associated with higher 30-day mortality compared with patients with a normal EF, but the overall mortality rate in the Vascular Quality Initiative falls within the acceptable range of Society for Vascular Surgery guidelines. Among patients with reduced EF, the type of cardiomyopathy seems to have a more important association with 30-day mortality than the severity of cardiomyopathy does.