Postoperative Outcomes Linked to Congestive Heart Failure in Arthroscopic Rotator Cuff Repair

doi:10.21203/rs.3.rs-5271429/v1

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Postoperative Outcomes Linked to Congestive Heart Failure in Arthroscopic Rotator Cuff Repair

https://doi.org/10.21203/rs.3.rs-5271429/v1

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Purpose: This study aims to explore potential complications and risk factors associated with arthroscopic rotator cuff repair (aRCR) in patients with congestive heart failure (CHF).

Methods: This study examined all individuals who underwent aRCR from 2015 to 2021, sourced from the American College of Surgeons National Surgical Quality Improvement database. The analysis encompassed patient demographics, comorbidities, and 30-day postoperative complications. Logistic regression was employed to analyze the postoperative complications linked to patients with CHF.

Results: Compared to patients without CHF, patients with CHF undergoing aRCR were independently associated with a significantly greater likelihood of experiencing any complication (OR 3.21, 95% CI 1.89-5.48; P < .001), sepsis (OR 13.04, 95% CI 2.45-69.31; P = .003), cardiac event (OR 7.76, 95% CI 1.59-37.97; P = .011), readmission (OR 3.61, 95% CI 1.78-7.35; P < .001), and non-home discharge (OR 5.43, 95% CI 2.27-13.02; P < .001).

Conclusion: CHF was identified as an independent risk factor for experiencing any complication, sepsis, cardiac event, readmission, and non-home discharge in patients undergoing aRCR. The increased risk of postoperative complications in CHF patients after aRCR highlights the need for diligent preoperative management of these patients to reduce the risk of severe complications and enhance surgical outcomes.

Level of evidence: Level III; Retrospective Cohort Comparison Using Large Database; Prognosis Study

heart failure

arthroscopic rotator cuff repair

postoperative complications

comorbidities

Arthroscopic rotator cuff repair (aRCR) is an increasingly popular method of treating rotator cuff tears and injuries [1, 2]. Previous work has sought to identify complications following aRCR, including hardware and mechanical complications, re-tear, and stability [3]. While it is generally known that patients with comorbidities experience worse outcomes following orthopaedic surgery, there is a paucity of literature on postoperative complications following aRCR in patients with congestive heart failure (CHF).

CHF remains one of the most prevalent health conditions worldwide, particularly among the elderly [4]. Notably, aRCR is a common procedure in older populations. As such, understanding the risk factors associated with comorbidities such as CHF in a postoperative state is critical for optimizing and ensuring appropriate patient care [5, 6].

Previous research in the orthopaedic literature has identified CHF as a significant risk factor for postoperative complications across various orthopaedic surgeries. For example, patients with heart failure experienced more postoperative complications following total knee arthroplasty, including longer length of stay, increased likelihood of reoperation, higher readmission rates, and other adverse outcomes [7]. CHF has also been associated with an increased risk of myocardial infarction following total joint arthroplasty and revision total shoulder arthroplasty [8–10].

While CHF has been studied in arthroplasty, its impact on outcomes in aRCR remains unexplored. The present study aims to investigate postoperative complications and associated risk factors among patients with CHF undergoing aRCR. We hypothesize that patients with CHF are at increased risk for postoperative complications compared to those without CHF.

The present study utilized the American College of Surgeons National Surgical Quality Improvement (NSQIP) database to investigate patients undergoing aRCR from 2015 to 2021. The NSQIP database is a validated resource for tracking surgical outcomes, with data sourced from over 600 de-identified hospitals across the United States, collected by trained surgical clinical reviewers. Since the database is entirely de-identified, this study is exempt from approval by the University's Institutional Review Board.

Patients undergoing aRCR were identified using Current Procedural Terminology (CPT) code 29827, excluding those under 18 years of age. Additional exclusion criteria included cases missing variables such as age, height, weight, gender, functional status, American Society of Anesthesiologists (ASA) classification, discharge destination, and CHF status.

Analyzed variables included patient demographics, comorbidities, preoperative laboratory values, and 30-day postoperative complications. Demographic variables covered sex, age, BMI, preoperative functional status, ASA classification, smoking status, and steroid usage. Preoperative comorbidities included insulin-dependent diabetes, hypertension requiring medication, chronic obstructive pulmonary disease (COPD), bleeding disorders, and disseminated cancer. The analysis also included various complications occurring within 30 days postoperatively, such as sepsis, septic shock, pneumonia, reintubation, cardiac event (cardiac arrest requiring resuscitation or myocardial infarction), bleeding requiring transfusion, deep vein thrombosis requiring therapy, pulmonary embolism, failure to wean off the ventilator within 48 hours, deep and superficial incisional surgical site infections (SSI), wound dehiscence, readmission, reoperation, non-home discharge, mortality, and length of stay (LOS) > 2 days. A composite variable, "any complication," was created to include any of the mentioned complications occurring within 30 days postoperatively.

A total of 47,601 patients underwent primary aRCR in NSQIP from 2015 to 2021. Of these, 1,039 cases were excluded as follows: 413 for missing height/weight, 1 for uncategorical gender, 548 for missing functional health status before surgery, 68 for missing ASA classification, and 9 for unknown discharge destination. There were 46,562 patients remaining after exclusion criteria: 46,436 patients were included in the no CHF cohort and 126 patients were included in the CHF cohort (Figure I). CHF was defined by NSQIP as the inability of the heart to pump enough blood to meet the metabolic needs of the body or a situation where the heart can do so only at increased ventricular filling pressure. The criteria used to qualify patients with CHF are delineated in Table I.

Statistical analyses were performed using SPSS Software version 26.0. Bivariate logistic regression was utilized to examine differences in demographics and comorbidities between the two groups. To identify independent relationships between CHF and postoperative complications, multivariate logistic regression was conducted, adjusting for significant associations. Results were expressed as odds ratios (OR) with 95% confidence intervals (CI), and statistical significance was determined at P < 0.05.

Figure I. Case selection schematic detailing patient selection process for arthroscopic rotator cuff reapir (aRCR) from 2015 to 2021. NSQIP, National Surgical Quality Improvement Program; ASA, American Society of Anesthesiologists.

Table I. Criteria used by NSQIP to designate patients with CHF. Criteria from both categories A and B must be met.

Criteria	Details
A. Diagnosis of heart failure	Documented by a physician or advanced provider.
B. Documentation of at least ONE of the following:
Active signs or symptoms	General symptoms: breathlessness, fatigue, palpitations, reduced exercise tolerance, increased time to recover after exercise, heart murmur, third heart sound (gallop rhythm), laterally displaced apical impulse, worsening cardiomegaly Congestion: pulmonary congestion/edema, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, peripheral edema, jugular venous dilatation, congested hepatomegaly, hepatojugular reflux, ascites, symptoms of gut congestion, nocturnal cough, wheezing, weight gain > 2 kg/week Hypoperfusion: cold clammy/sweaty extremities, oliguria, mental confusion, dizziness, narrow pulse pressure.
NYHA Functional Classification II-IV
Daily prescription of disease-modifying drugs for heart failure	Angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, mineralocorticoid receptor antagonists (MRA), angiotensin receptor blockers (ARB), angiotensin receptor neprilysin inhibitors (ARNI), diuretics, hydralazine and isosorbide dinitrate, and digoxin.
LVEF < 40% on the most recent measurement prior to surgery	can be outside of the 30-day preop timeframe
Elevated levels of natriuretic peptides	BNP ≥ 100 pg/mL or NT-proBNP ≥ 900 pg/mL.
Patients with devices:	ventricular assist device, implantable cardioverter-defibrillator, cardiac resynchronization therapy device

NYHA, New York Heart Association; LVEF, left ventricular ejection fraction; BNP, brain natriuretic peptide; NT-proBNP, N-terminal prohormone brain naturetic peptide.

Compared to patients without CHF, those undergoing aRCR with CHF were significantly associated with male sex (P < .001), older age (P < .001), greater BMI (P = .001), dependent functional status (P < .001), ASA classification ≥ 3 (P < .001), steroid use (P < .001), diabetes (P < .001), hypertension (P < .001), COPD (P < .001), bleeding disorder (P < .001), and disseminated cancer (P = .014) (Table II). Additionally, patients with CHF demonstrated a significantly greater likelihood of experiencing any complication (P < .001), as well as specific complications such as sepsis (P < .001), urinary tract infection (P = .003), cardiac event (P < .001), failure to wean off of ventilator (P < .001), readmission (P < .001), non-home discharge (P < .001), mortality (P < .001), and LOS > 2 days (P < .001) (Table III).

A multivariate regression analysis was conducted following the adjustment for all significant patient demographic and comorbidity factors (Table IV). Compared to patients without CHF, patients with CHF in aRCR were independently associated with a significantly greater likelihood of experiencing any complication (OR 3.21, 95% CI 1.89–5.48; P < .001), sepsis (OR 13.04, 95% CI 2.45–69.31; P = .003), cardiac event (OR 7.76, 95% CI 1.59–37.97; P = .011), readmission (OR 3.61, 95% CI 1.78–7.35; P < .001), and non-home discharge (OR 5.43, 95% CI 2.27–13.02; P < .001) (Table IV).

Table II. Demographics and Comorbidities of Patients undergoing aRCR without and with CHF. Bold P values indicate statistical significance with P < .05.

	No CHF	CHF
	Number (%)	Number (%)	p value
Overall	46436 (100.0)	126 (100.0)
Sex			< 0.001
Female	18875 (40.6)	43 (34.1)
Male	27561 (59.4)	83 (65.9)
Age			< 0.001
18–39	2307 (5.0)	0 (0.0)
40–64	21746 (46.8)	32 (25.4)
65–74	21957 (47.3)	91 (72.2)
≥ 75	426 (0.9)	3 (2.4)
BMI (kg/m^2)			0.001
< 18.5	171 (0.4)	0 (0.0)
18.5–24.9	6651 (14.3)	14 (11.1)
25.0-29.9	16153 (34.8)	26 (20.6)
≥ 30	23461 (50.5)	86 (68.3)
Functional status prior to surgery			< 0.001
Dependent	161 (0.3)	3 (2.4)
Independent	46275 (99.7)	123 (97.6)
ASA classification			< 0.001
≤ 2	30269 (65.2)	7 (5.6)
≥ 3	16167 (34.8)	119 (94.4)
Smoker			0.178
No	39661 (85.4)	113 (89.7)
Yes	6775 (14.6)	13 (10.3)
Steroid	(0.0)	(0.0)	< 0.001
No	45450 (97.9)	117 (92.9)
Yes	986 (2.1)	9 (7.1)
Comorbidities
Diabetes mellitus	7720 (16.6)	53 (42.1)	< 0.001
Hypertension	20888 (45.0)	111 (88.1)	< 0.001
COPD	1273 (2.7)	24 (19.0)	< 0.001
Bleeding disorder	622 (1.3)	13 (10.3)	< 0.001
Disseminated cancer	30 (0.1)	1 (0.8)	0.014

BMI, body mass index; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure.

Table III. Bivariate Analysis of 30-day Postoperative Complications Patients undergoing aRCR without and with CHF. Bold P values indicate statistical significance with P < .05.

	No CHF	CHF
	Number (%)	Number (%)	p value
Any complication	1184 (2.5)	18 (14.3)	< 0.001
Sepsis	23 (0.0)	2 (1.6)	< 0.001
Septic shock	4 (0.0)	0 (0.0)	-
Pneumonia	62 (0.1)	0 (0.0)	-
Reintubation	16 (0.0)	0 (0.0)	-
Urinary tract infection	91 (0.2)	2 (1.6)	0.003
Cerebrovascular event	17 (0.0)	0 (0.0)	-
Cardiac arrest or MI	35 (0.1)	2 (1.6)	< 0.001
Bleeding transfusions	5 (0.0)	0 (0.0)	-
Deep vein thrombosis	61 (0.1)	0 (0.0)	-
Pulmonary embolism	80 (0.2)	0 (0.0)	-
Failure to wean off ventilator	10 (0.0)	1 (0.8)	< 0.001
SSI	107 (0.2)	0 (0.0)	-
Wound dehiscence	7 (0.0)	0 (0.0)	-
Readmission	441 (0.9)	9 (7.1)	< 0.001
Reoperation	124 (0.3)	0 (0.0)	-
Nonhome discharge	210 (0.5)	7 (5.6)	< 0.001
Mortality	11 (0.0)	1 (0.8)	< 0.001
LOS > 2 days	320 (0.7)	5 (4.0)	< 0.001
Acute renal failure	4 (0.0)	0 (0.0)	-
Clostridioides difficile infection	8 (0.0)	0 (0.0)	-

MI, myocardial infarction; SSI, surgical site infection; LOS, length of stay; CHF, Congestive Heart Failure.

Table IV. Multivariate Analysis of 30-day Postoperative Complications in Patients undergoing aRCR with CHF compared to patients without CHF. Bold P values indicate statistical significance with P < .05.

	CHF
	OR, P value (95% CI)
Any complication	3.21, < .001 (1.89–5.48)
Sepsis	13.04, 0.003 (2.45–69.31)
Urinary tract infection	3.87, 0.072 (0.89–16.82)
Cardiac arrest or MI	7.76, 0.011 (1.59–37.97)
Failure to wean off ventilator	0.27, 0.249 (0.03–2.52)
Readmission	3.61, < .001 (1.78–7.35)
Nonhome discharge	5.43, < .001 (2.27–13.02)
Mortality	6.11, 0.139 (0.56–67.14)
LOS > 2 days	2.25, 0.099 (0.86–5.87)

LOS, length of stay; CHF, Congestive Heart Failure.

This study comprised patients with and without CHF who underwent aRCR between 2015 and 2021. Using the NSQIP database, we identified early postoperative complications associated with CHF. After applying multivariate analysis and adjusting for major demographic factors and comorbidities, we determined that CHF was an independent risk factor for experiencing any complication, sepsis, cardiac events, readmission, or non-home discharge following aRCR.

CHF encompasses a variety of etiologies, many of which are common in elderly individuals. The most common cause of CHF is ischemic heart disease due to coronary artery pathologies, but other causes include valvular heart disease, hypertension, chronic obstructive pulmonary disease (COPD), rheumatic heart disease, and obesity [4, 11–14]. We found that aRCR patients with CHF were older than patients without CHF. This is noteworthy as aRCR is increasingly performed in older adults, a demographic more commonly affected by CHF [15]. The increased prevalence of CHF among older adults is relevant as these patients are more likely to experience complications, which can adversely impact surgical outcomes [16]. Understanding how CHF affects recovery in older adults undergoing aRCR can inform clinical decisions and potentially improve outcomes for this at-risk population.

We found that patients undergoing aRCR with CHF were more likely to have greater BMI, as well as comorbid diabetes, compared to patients without CHF. Higher BMI has been closely linked to an increased risk of developing CHF [17]. Excess body weight imposes additional stress on the cardiovascular system, contributing to the development of coronary artery disease, a notable risk factor for CHF [18]. As a result, managing BMI can play a crucial role in preventing and managing CHF. Diabetes may also exacerbate the risk and severity of heart failure by increasing cardiovascular strain through mechanisms such as oxidative stress, inflammation, and endothelial dysfunction. These factors can impair heart function and contribute to "diabetic cardiomyopathy" [19]. Specifically, diabetes has been found to be a significant independent predictor of cardiovascular mortality [20].

The present study also found that patients undergoing aRCR with CHF had higher rates of hypertension and COPD compared to those without CHF. Previous research supports the connection between CHF and hypertension, describing systolic blood pressure as the most significant factor influencing complications in patients with CHF [13, 21, 22]. Hypertensive males had twice the hazard ratio when compared to normotensive individuals, while hypertensive females had three times the hazard ratio [21]. Effective management of hypertension is known to alleviate the severity of CHF [22, 23]. Additionally, COPD has also been identified as another common risk factor for the development of CHF. COPD has been identified as a significant short-term predictor of mortality and cardiovascular issues in patients hospitalized for heart failure [24]. Evaluating these comorbidities provides deeper insights into the complex nature of CHF.

After controlling for comorbidities, patients with CHF were found to have over three times the likelihood of experiencing any complication in this study. Previous work in orthopedics has reported similar increased odds of complications for patients with CHF [7, 10, 25]. For example, patients with CHF following total knee arthroplasty were more likely to experience longer LOS, reoperation, and readmission [26]. Similarly, patients with CHF undergoing revision total shoulder arthroplasty were at increased risk of complications [10]. Our results also indicated that patients with CHF had higher odds of readmission and non-home discharge following the operation. This aligns with the broader understanding that worsening heart failure can impact discharge outcomes, often necessitating more intensive post-surgical care [27]. Moreover, we found that patients with CHF undergoing aRCR were approximately 13 times more likely to develop sepsis postoperatively. Similar investigations in patients undergoing total hip arthroplasty have demonstrated a higher likelihood of postoperative sepsis among those with CHF[28].

Furthermore, the CHF cohort demonstrated over seven times the risk of experiencing a cardiac event, including cardiac arrest or myocardial infarction. This finding aligns with existing literature, which identifies cardiovascular disease as a significant risk factor for myocardial infarction in patients undergoing orthopedic arthroplasty surgery [29–31]. To address these heightened risks, preoperative management strategies should prioritize optimizing cardiac function, which may involve controlling heart failure symptoms and managing comorbidities such as COPD and diabetes. Additionally, assessing cardiac biomarkers such as B-type natriuretic peptide (BNP) and C-reactive protein (CRP) can provide valuable insights, as these markers are key indicators of significant postoperative cardiovascular events in patients with cardiac pathology undergoing non-cardiac surgery [32]. Ensuring that heart failure is well-managed before surgery can significantly reduce the risk of perioperative and postoperative complications [32]. Given the mounting evidence of its impact and the findings of our study, CHF should be considered a crucial factor in preoperative risk assessment.

Considering the comprehensive nature of the NSQIP database, it presents certain inherent limitations. One limitation of this study is the small sample size of patients with CHF, as less than 1% of those undergoing aRCR met the NSQIP criteria for this condition. Furthermore, NSQIP does not track patients beyond the 30-day postoperative window, which precludes the identification of complications that may arise later in the recovery process. Despite these limitations, our findings demonstrate statistical significance and relatively large odds ratios, aligning with existing literature on CHF in the orthopedic context. This underscores the critical impact of a CHF diagnosis on the decision-making process and the preoperative workup and management strategies for patients undergoing aRCR.

Congestive heart failure was identified as an independent risk factor for experiencing any complication, sepsis, cardiac event, readmission, or non-home discharge in patients undergoing aRCR. The increased risk of postoperative complications in patients undergoing aRCR with CHF underscores the need for careful management of these patients to mitigate the risk of severe complications and improve overall surgical outcomes.

Authors are required to disclose financial or non-financial interests that are directly or indirectly related to the work submitted for publication. There is no funding to be declared.

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No competing interests reported.

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Postoperative Outcomes Linked to Congestive Heart Failure in Arthroscopic Rotator Cuff Repair

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