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Outcomes Of Endovascular Aneurysm Repair In Patients With Decreased Ejection Fraction
Kirthi S. Bellamkonda, MSc, Cheryl Zogg, MSPH MHS, Nihar Desai, MD MPH, Naiem Nassiri, MD, Raul J. Guzman, MD, Cassius I. Ochoa Chaar, MD MS.
Yale University School of Medicine, New Haven, CT, USA.

Objective: Endovascular aneurysm repair (EVAR) has become the first line therapy for AAA repair, particularly in patients with significant cardiac comorbidities. However, the effects of decreased ejection fraction on patient outcomes remain unknown. The aim of this study is to compare outcomes in patients with normal versus decreased ejection fraction undergoing EVAR.Methods: Data from the Vascular Quality Initiative (VQI) module for EVAR was reviewed (2003-2019). Patients with symptomatic AAA or missing variables were excluded. Patients were stratified into very low EF (VLEF <30%), low EF (LEF = 30-50%) and normal EF (NEF > 50%). Baseline characteristics and outcomes were compared. Multivariable regression was performed to identify factors independently associated with mortality. Results: There were 24,663 EVARs ((VLEF n=969 (3.9%), LEF n=4647 (18.8%)) with mean follow up of 444 days. Patients with VLEF and LEF were more likely to be younger, male, and functionally dependent compared to patients with NEF. Patients with VLEF and LEF were significantly more likely to have coronary artery disease (CAD) as defined by a history of myocardial infarction or surgical/interventional cardiac treatment, compared with patients in the NEF group. Patients with VLEF and LEF were more likely to suffer post-operative myocardial infarction, dysrhythmia, acute kidney injury, and overall morbidity. The 30-day mortality was significantly higher in VLEF and LEF compared to patients with NEF (1.75% vs 1.7% vs 0.7%, P<0.001). (Table) On multivariable analysis, VLEF and LEF were independently associated with higher 30-day and long-term mortality when controlling for age, race, sex, history of CAD, body mass index, transfer status, functional status, hypertension, diabetes, COPD, and anesthesia type. When evaluated separately, VLEF was associated with increased mortality compared to LEF (OR = 1.5 [1.25 -1.8]) and NEF (OR = 2.27 [1.91 -2.7]).Conclusions: Decreased ejection fraction was identified in 22.7% of patients undergoing elective EVAR. Although patients with decreased EF have a higher morbidity and mortality rates, outcomes are acceptable and fall within the SVS guidelines of 2% perioperative mortality.

Ejection Fraction
	<30%	30-50%	>50%
n=	969	4647	19047
	n (%)	n (%)	n (%)	P value
Age (mean±SD)	72.4±8.62,3	73.8±8.71	73.8±8.61	<0.001*
Male Sex	883 (91.12)2,3	4117 (88.59)1	15103 (79.29)1,2	<0.001*
Race				0.016*
White	851 (87.82)2,3	4196 (90.29)1,3	17150 (90.04)1,2
African American	72 (7.43)2,3	253 (5.44)1,3	981 (5.15)1,2
Other	46 (4.75)2,3	198 (4.26)1,3	916 (4.81)1,2
BMI (mean±SD)	27.3±5.32,3	28.1±5.81	28.2±5.71	<0.001*
Transfer from HCF	44 (4.54)2,3	137 (2.95)1,3	443 (2.33)1,2	<0.001**
Dependent functional status	386 (39.83)3	1771 (38.11)3	6534 (34.3)1,2	<0.001
Comorbidities
Prior Smoker	571 (58.93)	2723 (58.6)3	10783 (56.61)2	0.025*
Hypertension	857 (88.44)3	4168 (89.69)3	16197 (85.04)1,2	<0.001*
Diabetes	198 (20.43)3	925 (19.91)3	3010 (15.8)1,2	<0.001*
Coronary Artery Disease	737 (76.06)2,3	3270 (70.37)1,3	7594 (39.87)1,2	<0.001*
Congestive Heart Failure	649 (66.98)2,3	1591 (34.24)1,3	1816 (9.53)1,2	<0.001*
COPD	391 (40.35)2,3	1701 (36.6)1	6715 (35.25)1	0.002*
Hospitalization
ASA 4+	191 (19.71)2,3	513 (11.04)1,3	1303 (6.84)1,2	<0.001*
General Anesthesia	826 (85.24)3	4228 (90.98)3	17410 (91.41)1,2	<0.001*
Operative time (mean±SD)	141.8±73.83	138.7±75.33	134.7±70.31,2	<0.001*
EBL (mean±SD)	213.3±348.4	208.9±310.33	193.0±345.22	0.006*
Days in ICU (mean±SD)	1.0±2.32,3	0.7±2.091,3	0.6±1.61,2	<0.001*
Days in hospital (mean±SD)	4.9±17.8	3.1±6.2	3.4±28.9	0.129
Postoperative complications
Myocardial Infarction	12 (1.24)	65 (1.4)3	157 (0.82) 2	0.001*
Dysrhythmia	39 (4.02)2,3	125 (2.69)1	435 (2.28)1	0.001*
Congestive Heart Failure	30 (3.1)2,3	66 (1.42)1,3	110 (0.58)1,2	<0.001*
Pneumonia	17 (1.75)	83 (1.79)	268 (1.41)	0.127
Acute Kidney Injury	22 (2.27)3	78 (1.68)3	238 (1.25)1,2	0.004*
Dialysis Dependency	1 (0.1)	13 (0.28)	29 (0.15)	0.151
Leg ischemia	9 (0.93)	34 (0.73)	164 (0.86)	0.654
Gut ischemia	5 (0.52)	20 (0.43)	76 (0.4)	0.831
Surgical Site Infection	3 (0.31)	19 (0.41)	47 (0.25)	0.169
Stroke	2 (0.21)	10 (0.22)	34 (0.18)	0.864
Bleeding	3 (0.31)	10 (0.22)	36 (0.19)	0.870
Reoperation	23 (2.37)	90 (1.94)	382 (2.01)	0.669
Access site occlusions	3 (0.31)	4 (0.09)	31 (0.16)	0.222
Conversion to open repair	1 (0.1)	6 (0.13)	21 (0.11)	0.939
Total morbidity	109 (11.25)2,3	390 (8.39)1,3	1342 (7.05)1,2	<0.001*
30-day mortality	17 (1.75)3	79 (1.7)3	129 (0.68)1,2	<0.001*
Long-term mortality	219 (22.6)2,3	775 (16.68)1,3	2126 (11.16)1,2	<0.001*
Table 1: Characteristics and outcomes of patients with normal and depressed ejection fraction undergoing endovascular abdominal aortic aneurysm repair. Abbreviations: Healthcare Facility (HCF), Chronic Obstructive Pulmonary Disease (COPD), American Society of Anesthesiologists Score (ASA), Abdominal aortic aneurysm (AAA), Estimated Blood Loss (EBL), Intensive Care Unit (ICU) Post Hoc Analysis Key: 1Significantly different from VLEF, 2Significantly different from LEF, 3Significantly different from NEF

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