Heart Failure With Reduced Ejection Fraction Is Associated With Greater Cardiovascular Risk Following Lumbar Interbody Fusion

Study Design Retrospective cohort study. Objective To compare perioperative cardiovascular outcomes between patients with heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) following transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). Methods The TriNetX Research Network was used to identify patients undergoing elective TLIF or PLIF between 2011 and 2025. Cohorts were defined by heart failure phenotype and propensity score–matched (PSM) 1:1 for baseline demographics and comorbidities. Outcomes included postoperative atrial fibrillation or flutter (AF/AFL), myocardial infarction (MI), and secondary complications within 90 days. Odds ratios with 95% confidence intervals were calculated. Significance was defined as p < 0.05. Results Of 46,431 patients, 1,253 (2.7%) had HFrEF, 1,920 (4.1%) had HFpEF, and 43,258 (93.2%) had no heart failure. After PSM, both phenotypes carried elevated risk relative to non-HF controls across measured complications, including acute respiratory failure, pneumonia, AF/AFL, acute kidney injury, venous thromboembolism, and 90-day emergency department visits (all p<0.05). In the direct phenotype comparison (1,217 matched pairs), acute MI occurred more frequently in HFrEF than HFpEF patients (14.4% vs. 8.7%, p<0.001). HFrEF was associated with greater odds of acute MI (OR 1.760 [95% CI: 1.363, 2.273], p<0.001) and AF/AFL (OR 1.278 [95% CI: 1.079, 1.513], p=0.005) compared with HFpEF. Conclusion Among patients with heart failure undergoing TLIF or PLIF, those with HFrEF are at increased risk of postoperative AF/AFL and MI compared with HFpEF patients. These findings highlight the importance of distinguishing heart failure phenotype during preoperative risk stratification and may support enhanced perioperative precautions.