Pre-operative Anemia as a Risk Factor of Morbidity and Mortality in Valvular Surgeries

Preoperative Anemia and Valvular Surgeries


  • Sardar Saud Abbas Department of Cardiothoracic Anesthesia, Rehman Medical Institute, Peshawar, Pakistan
  • Muhammad Wasim Sajjad Department of Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, Pakistan
  • Hamid Naeem Cardiac Intensive Care Unit, Rehman Medical Institute, Peshawar, Pakistan
  • Mujahid Ul Islam Department of Cardiothoracic Anesthesia, Rehman Medical Institute, Peshawar, Pakistan
  • Imran Khan Department of Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, Pakistan
  • Ahsan Sabir Department of Cardiothoracic Anesthesia, Rehman Medical Institute, Peshawar, Pakistan
  • Owais Imran Cardiac Intensive Care Unit, Rehman Medical Institute, Peshawar, Pakistan
  • Umair Arshad Department of General Anesthesia, Peshawar General Hospital, Peshawar, Pakistan
  • Syed Nauman Shah Department of Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, Pakistan
  • Rimshah Afridi Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan



Anemia, Hemoglobin, Hematocrit, Heart Failure, Morbidity, Red Cell Concentrate, Valvular Surgeries


Pre-operative anemia can be a hindrance to speedy recovery and will increase blood transfusion intraoperative and post operatively. Objective: To find a correlation between preoperative anemia and the subsequent morbidity and mortality rates in patients undergoing valvular surgeries. Methods: A retrospective observational study, involving 493 valvular surgeries’ patients. All patients had the same anesthetic and surgical techniques. According to the WHO, anemia is a hemoglobin level < 13 g/dl for men and <12 g/dl for women. Clinical variables were compared using chi-square and independent t-test. Results: The patients received cardiac surgery for valvular heart disorders and had an average age of 42.2±14.1 years, with 60.9% being male. Most patients exhibited NYHA III (48.9%) and CCS III (36.5%) functional class symptoms. Highest comorbidity was hypertension (35.1%), followed by diabetes (14.4%) and dyslipidemia (6.5%). 43.2% were anemic and older than non-anemic individuals (P=0.02). Anemic people had a significantly greater incidence of HTN (P 0.02) and DM (P < 0.001). Both groups exhibited identical perfusion and cross-clamp periods (P=0.4 vs. P=0.3). Though not statistically significant (P=0.08), non-anemic patients needed more intraoperative blood or blood product transfusions. Patients with anemia have worse outcomes, including increased rates of in-hospital mortality (P=0.03), extended artificial breathing (P=0.04), and postoperative blood/product transfusion (P<0.001). 44.8% of anemic individuals needed RCC, 41.9% FFP, and 41.4% platelets. Conclusions: anemia is associated with the poorest post-operative results. There is conflicting information about the impact of preoperative anemia, particularly iron deficiency anemia, on valvular surgery.

Author Biography

Mujahid Ul Islam, Department of Cardiothoracic Anesthesia, Rehman Medical Institute, Peshawar, Pakistan



Maakaron JE, Taher AT, Conrad ME. Anemia. 2023. [Last cited: 1st March 2024]. Available at:

Johnson RL and Rubenstein SD. Anemia in the emergency department: evaluation and treatment. Emergency Medicine Practice. 2013 Nov; 15(11): 1-5.

Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016 Oct; 388(10053): 1545-602.

Peyrin-Biroulet L, Williet N, Cacoub P. Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review. The American Journal of Clinical Nutrition. 2015 Dec; 102(6): 1585-94. doi: 10.3945/ajcn.114.103366. DOI:

Global News Wire. Anemia Treatment Drugs: 2019 Global Market Study; Analyzed by Type of Anemia, Type of Drug, and Geography. 2019. [Last Cited: 1st march 2024]. Available at:

Nappi J. Anemia in patients with coronary artery disease. American Journal of Health-System Pharmacy. 2003 Jul; 60(suppl_3): S4-8. doi: 10.1093/ajhp/60.suppl_3.S4. DOI:

Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. The Lancet. 1996 Oct; 348(9034): 1055-60. doi: 10.1016/S0140-6736(96)04330-9. DOI:

van Straten AH, Külcü K, Özdemir HI, Elenbaas TW, Hamad MA. Preoperative hemoglobin level as a predictor of mortality after aortic valve replacement. Journal of Cardiothoracic and Vascular Anesthesia. 2013 Aug; 27(4): 716-22. doi: 10.1053/j.jvca.2012.12.021. DOI:

Elmistekawy E, Rubens F, Hudson C, McDonald B, Ruel M, Lam K, et al. Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery. European Journal of Cardio-Thoracic Surgery. 2013 Dec; 44(6): 1051-6. doi: 10.1093/ejcts/ezt143. DOI:

Vincentelli A, Susen S, Le Tourneau T, Six I, Fabre O, Juthier F et al. Acquired von Willebrand syndrome in aortic stenosis. New England Journal of Medicine. 2003 Jul; 349(4): 343-9. doi: 10.1056/NEJMoa022831. DOI:

De Backer O, Arnous S, Lønborg J, Brooks M, Biasco L, Jönsson A et al. Recovery from anemia in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation–prevalence, predictors and clinical outcome. PloS One. 2014 Dec; 9(12): e114038. doi: 10.1371/journal.pone.0114038. DOI:

Hogervorst EK, Rosseel PM, van de Watering LM, Brand A, Bentala M, van der Bom JG et al. Intraoperative anemia and single red blood cell transfusion during cardiac surgery: an assessment of postoperative outcome including patients refusing blood transfusion. Journal of Cardiothoracic and Vascular Anesthesia. 2016 Apr; 30(2): 363-72. doi: 10.1053/j.jvca.2015.10.021. DOI:

Von Heymann C, Kaufner L, Sander M, Spies C, Schmidt K, Gombotz H et al. Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? The Journal of Thoracic and Cardiovascular Surgery. 2016 Nov; 152(5): 1412-20. doi: 10.1016/j.jtcvs.2016.06.010. DOI:

Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA. 2007 Jun; 297(22): 2481-8. doi: 10.1001/jama.297.22.2481. DOI:

Karkouti K, Wijeysundera DN, Beattie WS. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 2008 Jan; 117(4): 478-84. doi: 10.1161/CIRCULATIONAHA.107.718353. DOI:

Bell ML, Grunwald GK, Baltz JH, McDonald GO, Bell MR, Grover FL et al. Does preoperative hemoglobin independently predict short-term outcomes after coronary artery bypass graft surgery? The Annals of Thoracic Surgery. 2008 Nov; 86(5): 1415-23. doi: 10.1016/j.athoracsur.2008.07.088. DOI:

De Santo L, Romano G, Della Corte A, de Simone V, Grimaldi F, Cotrufo M et al. Preoperative anemia in patients undergoing coronary artery bypass grafting predicts acute kidney injury. The Journal of Thoracic and Cardiovascular Surgery. 2009 Oct; 138(4): 965-70. doi: 10.1016/j.jtcvs.2009.05.013. DOI:

Khanna MP, Hébert PC, Fergusson DA. Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion. Transfusion medicine reviews. 2003 Apr; 17(2): 110-9. doi: 10.1053/tmrv.2003.50008. DOI:

Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. The Annals of Thoracic Surgery. 2006 May; 81(5): 1650-7. doi: 10.1016/j.athoracsur.2005.12.037. DOI:

Banbury MK, Brizzio ME, Rajeswaran J, Lytle BW, Blackstone EH. Transfusion increases the risk of postoperative infection after cardiovascular surgery. Journal of the American College of Surgeons. 2006 Jan; 202(1): 131-8. doi: 10.1016/j.jamcollsurg.2005.08.028. DOI:

Reeves BC and Murphy GJ. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Current Opinion in Anesthesiology. 2008 Oct; 21(5): 669-73. doi: 10.1097/ACO.0b013e32830dd087. DOI:



DOI: 10.54393/pjhs.v5i03.1269
Published: 2024-03-31

How to Cite

Abbas, S. S., Sajjad, M. W., Naeem, H., Ul Islam, M., Khan, I., Sabir, A., Imran, O., Arshad, U., Shah, S. N., & Afridi, R. (2024). Pre-operative Anemia as a Risk Factor of Morbidity and Mortality in Valvular Surgeries: Preoperative Anemia and Valvular Surgeries. Pakistan Journal of Health Sciences, 5(03), 12–16.



Original Article