Thyroidectomy in cardiovascularly fragile patients: a 21-year single-center cohort study of 1000 consecutive cases (2004–2025)

Background: Perioperative management of thyroidectomy in patients with established cardiovascular disease (CVD) remains a significant clinical challenge. This study aimed to systematically assess short- and long-term surgical outcomes, identify risk factors, and evaluate perioperative resource utilization in this high-risk population. Methods: This retrospective cohort study was conducted at a tertiary endocrine surgery center and included all consecutive adults with pre-existing CVD who underwent open thyroidectomy between January 2004 and March 2025. Cardiovascular diagnoses were classified according to contemporary European Society of Cardiology and Association/American College of Cardiology guidelines, and predefined eligibility criteria were applied to ensure a clinically homogeneous population. The primary endpoint was 30-day composite postoperative cardiovascular morbidity, with secondary endpoints including non-cardiac surgical complications, perioperative resource utilization, and 1-year all-cause mortality. Multivariable logistic regression and relevant inferential statistics were used to evaluate predictors and temporal trends, in accordance with the STROCSS recommendations, data protection regulations, and institutional ethical oversight. Results: The study analyzed 1000 patients (mean age 69.2 years, 65.4% female). Unadjusted cardiovascular morbidity rates differed across study periods (from 17.9% to 9.8%, P for trend < 0.001); however, risk-adjusted analyses substantially attenuated these temporal differences, suggesting that evolving case selection contributed to the observed trend. Intensive care unit (ICU) utilization increased slightly from 5.7% to 7.4%, and median hospital stay increased non-significantly from 3.5 to 3.8 days. No in-hospital or 30-day mortality was observed; all-cause 1-year mortality was 0.3%, restricted to patients with ongoing major comorbidity. Overlap between cardiac and surgical complications was infrequent (1.9%) but was associated with prolonged hospitalization. Multivariable analysis identified age ≥70, American Society of Anesthesiologists IV, left ventricular dysfunction, chronic kidney disease, and intraoperative instability as significant predictors of postoperative cardiac events. Neither surgical indication (benign, malignant, or toxic) nor preoperative thyroid-stimulating hormone levels independently predicted morbidity in this pre-optimized cardiac cohort. Conclusion: In our center, among carefully selected and optimized patients with pre-existing CVD, open thyroidectomy was associated with clinically relevant perioperative cardiovascular morbidity (overall rate 8.9%). Unadjusted outcome rates differed across study eras, but risk-adjusted analyses substantially attenuated these temporal differences, indicating that changes in case selection rather than demonstrable advances in perioperative care largely accounted for the observed trends. These findings provide descriptive reference data on perioperative cardiovascular risk in thyroidectomy within a single high-volume endocrine surgery program.