Dysphagia: A Novel Risk Factor for Poor Outcomes Following Cardiovascular Procedures

Abstract

Background

Dysphagia, an increasingly recognized clinical marker of frailty, is prevalent among older adults yet its impact on cardiovascular postprocedural outcomes remains undetermined. This study evaluated the association between dysphagia and adverse outcomes following major cardiac interventions.

Methods

Using the TriNetX database (2020–2024), we retrospectively identified adults with and without dysphagia who underwent coronary artery bypass graft, implantable cardioverter‐defibrillator placement, transcatheter aortic valve replacement, surgical aortic valve replacement, or mitral transcatheter edge‐to‐edge repair. Cohorts were propensity matched based on demographics and comorbidities; a sensitivity analysis incorporated additional frailty markers. The 90‐day and 1‐year risks of mortality, stroke, aspiration pneumonia, infectious pneumonia, hypoxemia, intubation, foreign body in respiratory tract, and esophagogastroduodenoscopy were measured. Kaplan–Meier analyses on survival probability were performed. Hazard ratios (HRs) for mortality, and risk ratios for all outcomes with 95% CIs were calculated.

Results

Propensity matched cohorts of patients with and without dysphagia (coronary artery bypass graft, n=5152; implantable cardioverter‐defibrillator, n=4112; transcatheter aortic valve replacement, n=4066; surgical aortic valve replacement, n=1982; mitral transcatheter edge‐to‐edge repair, n=710) were well balanced. Dysphagia was associated with significantly increased 90‐day mortality following coronary artery bypass graft (HR, 1.321), implantable cardioverter‐defibrillator implantation (HR, 1.398), transcatheter aortic valve replacement (HR, 1.736), and surgical aortic valve replacement (HR, 1.341) (all P<0.01) but not mitral transcatheter edge‐to‐edge repair. Dysphagia also increased the 1‐year risk of stroke, hypoxemia, infectious pneumonia, and intubation across all procedures.

Conclusions

Dysphagia is associated with increased short‐term morbidity and mortality following common cardiovascular procedures. Incorporating dysphagia screening into perioperative workflows may improve patient selection and resource allocation, supporting its inclusion in guideline‐directed risk assessment and perioperative optimization pathways.

Nonstandard Abbreviations and Acronyms

mTEER

mitral transcatheter edge‐to‐edge repair

SAVR

surgical aortic valve replacement

SMD

standard mean difference

TAVR

transcatheter aortic valve replacement

Clinical Perspective.

What Is New?

• In a large multicenter cohort, a preoperative diagnosis of dysphagia was associated with higher 90‐day and 1‐year mortality following common cardiovascular procedures, including coronary artery bypass grafting, valve interventions, and implantable cardioverter defibrillator implantation.

• Dysphagia was also associated with increased postoperative complications, including stroke, pneumonia, hypoxemia, and need for intubation across both surgical and transcatheter procedures; dysphagia represents an observable marker of physiologic vulnerability that is not routinely incorporated into cardiovascular procedural risk assessment.

What Are the Clinical Implications?

• Recognition of dysphagia before cardiovascular procedures may improve perioperative risk stratification and identification of patients with reduced physiologic reserve; incorporation of brief dysphagia screening tools into preoperative workflows may facilitate earlier multidisciplinary evaluation and mitigation of aspiration‐related complications.

Dysphagia, or impaired swallowing, is a common yet underrecognized condition, typically classified as oral, oropharyngeal, or esophageal depending on the anatomical level of dysmotility. Oropharyngeal dysphagia, is increasingly recognized as a geriatric syndrome, strongly associated with frailty, sarcopenia, and malnutrition. ¹ Its prevalence is strikingly high at 47.5% in older patients hospitalized in acute geriatric units, ² , ³ 51% in nursing home residents, ⁴ and 91% in older patients hospitalized with community‐acquired pneumonia. ⁵ Despite its frequency, dysphagia remains consistently underdiagnosed in aging populations with cardiovascularconditions, with low referral rates following cardiac surgery, ⁶ and underuse of dedicated instrumental assessments contributing to underestimation, particularly in higher‐risk surgical cohorts.

Dysphagia is a clinically significant condition that has been independently associated with aspiration pneumonia, malnutrition, prolonged hospitalization, readmissions, and mortality ¹ , ⁷ Among patients undergoing cardiac surgical procedures, dysphagia has emerged as both a consequence of procedural stress and a predictor of adverse postoperative outcomes. Among patients requiring prolonged postoperative intubation, over half develop dysphagia, leading to delayed oral intake and extended length of stay. ⁸ Instrumentation commonly used in cardiac procedures, such as transesophageal echocardiography, has also been implicated, with one study reporting a 7.8‐fold increase in adjusted odds of postoperative dysphagia among patients undergoing transesophageal echocardiography. ⁹ Beyond periprocedural complications, dysphagia is an emerging predictor of hospital‐associated disability, which itself confers an increased long‐term risk of major adverse cardiac and cerebrovascular events. ¹⁰ Given the rising number of cardiovascular surgical procedures, particularly transcatheter interventions, ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ recognition of dysphagia as a modifiable perioperative factor has become increasingly important for enhancing preoperative assessment and guiding individualized clinical decision‐making.

In the present study, we examined the association between a diagnosis of dysphagia and adverse outcome in patients undergoing common cardiovascular procedures, including coronary artery bypass grafting (CABG), implantable cardioverter‐defibrillator (ICD) implantation, transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), and mitral transcatheter edge‐to‐edge repair (mTEER). Our primary objectives were to report both the 90‐day and 1‐year postoperative risk of mortality, stroke, and respiratory complications associated with a documented diagnosis of dysphagia. Given the emerging role of dysphagia as a clinical marker of frailty, we hypothesized that its presence would significantly worsen postoperative outcomes and be a sensitive marker for preoperative risk stratification.

METHODS

Data Availability

The data used in this study were accessed through the TriNetX US Collaborative Network. As these data are proprietary and governed by institutional data use agreements, the authors are restricted from public redistribution. Qualified investigators may access the underlying data sets directly through the TriNetX platform. To facilitate study replication, cohort selection criteria and analytic methodologies used in this study are provided.

Data Source

The present study employed a retrospective cohort analysis using the TriNetX Analytics Network, a globally federated health research network that aggregates real‐time electronic health record data from >150 million patients from 111 health care organizations, predominately located in the United States. Clinical variables encompassing diagnoses, procedures, medications, laboratory results, and select genomic data are all derived directly from structured and unstructured electronic health record documentation through standardized natural language processing and data harmonization protocols to ensure the validity and consistency of extracted variables before inclusion in the analytic platform. The TriNetX database is fully compliant with the Health Insurance Portability and Accountability Act and includes only deidentified patient data in accordance with the act's standards, with the exclusion of names, contact information, and social security numbers, thus ensuring the protection of patient privacy. In accordance with federal regulations for research on deidentified data sets, this study was deemed exempt from institutional review board review.

Study Population

Cohort identification and data extraction were conducted on December 6, 2025, using the TriNetX Analytics platform. Adult patients ≥18 years who underwent 1 of 5 major cardiovascular surgical procedures, including CABG, ICD implantation, TAVR, SAVR, or mTEER, between December 6, 2020 and December 6, 2024, were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM), ICD‐10 Procedure Coding System (ICD‐10‐PCS), and Current Procedural Terminology codes (Table S1). This time frame was used to ensure analysis of a contemporary cohort of patients who would have a minimum of 1‐year follow‐up data following operation. Patients were subsequently stratified into 2 separate cohorts depending on the presence or absence of a documented diagnosis of dysphagia (R13.1) before the procedure, for a total of 10 cohorts. Figure 1 depicts this study design as a workflow diagram.

Figure 1. Flow diagram of cohort construction.

CABG indicates coronary artery bypass graft; ICD, implantable cardioverter‐defibrillator; mTEER, mitral transcatheter edge‐to‐edge repair; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

Covariables and Propensity Matching

Each cohort with dysphagia was matched to the corresponding cohort without dysphagia based on the same cardiovascular procedure, yielding 5 distinct matched analyses using 1:1 propensity‐score matching with greedy nearest‐neighbor matching to reduce potential confounding. The TriNetX platform supports 1:1 nearest‐neighbor matching; therefore, a 1:1 matching strategy was used. Matching covariates included demographic variables (age at index procedure, sex, and race), and key comorbidities known to influence procedural outcomes, including hypertension, hyperlipidemia, diabetes, obesity (body mass index >30 kg/m²), morbid obesity (body mass index >40 kg/m²), nicotine dependence, alcohol‐related disorders, chronic kidney disease, chronic obstructive pulmonary disease, heart failure, coronary artery disease, and stroke. Covariates were selected based on clinical relevance and prior knowledge of factors influencing cardiovascular surgical outcomes, and potential relationships between variables were considered in model implementation to reduce the risk of model misspecification. By matching for these prevalent cardiovascular conditions, we ensured that baseline disease severity was comparable between groups, thereby mitigating the confounding influence of preexisting cardiac pathology. A sensitivity analysis was performed using an expanded matching model that additionally incorporated 10 recognized frailty markers: gait and movement abnormalities, physical debility, malnutrition, abnormal weight loss, cachexia, sarcopenia, falling history, dementia, incontinence, and pressure ulcers. Covariate balance was assessed using standardized mean differences (SMDs), with values <0.1 considered indicative of acceptable balance. For unmatched variables, differences were evaluated using Student's t test for continuous variables (eg, age) and χ² tests for categorical variables. Matching was deemed successful if all prespecified covariates demonstrated postmatch SMDs <0.1 threshold.

Statistical Analysis

Following propensity score matching, primary outcomes included the 90‐day and 1‐year risks of all‐cause mortality, ischemic stroke, aspiration pneumonia, infectious pneumonia, hypoxemia, foreign body in respiratory tract, esophagogastroduodenoscopy, and endotracheal intubation. Event rates were calculated as the proportion of patients experiencing each outcome during the specified time interval relative to the total number of patients in the matched cohort. Risk comparisons between groups with and without dysphagia were conducted using the 2‐proportion z‐test, and risk ratios (RRs) with corresponding 95% CIs were reported. In accordance with TriNetX privacy policy, outcome comparisons were not conducted when the number of events for both cohorts were ≤10, as exact counts are suppressed for confidentiality. Kaplan–Meier survival analysis was used to estimate survival probabilities at 90 days and 1 year, with log‐rank tests employed for between‐group comparisons. Hazard ratios (HR) for 1‐year survival were calculated with 95% CIs using Cox proportional hazards regression models accounting for the matched study design. The proportional hazards assumption for all Cox regression models was assessed using the Schoenfeld residual equivalent test and visual inspection of the generated Kaplan–Meier survival curves, which were reproduced graphically using Microsoft Excel. Similarly, forest plots displaying risk ratios across outcomes were constructed using Excel for visual interpretation. All hypothesis testing was 2 sided, with a significance threshold set at a 2‐tailed α=0.05. P values less than this threshold were considered statistically significant. All statistical analysis for this study was performed using the TriNetX built‐in analytics package.

RESULTS

Clinical Characteristics

Cohort sizes were established for adult patients with and without a documented preprocedural diagnosis of dysphagia who underwent 1 of 5 cardiovascular procedures (Tables S2 through S6), including CABG (n=5157 versus 68 903) ICD implantation (n=4115 versus 37 408), TAVR (n=4071 versus 38 224), SAVR (n=1984 versus 3462), or mTEER (n=714 versus 4797). SAVR was therefore the procedure with the greatest percentage of patients with dysphagia (36.4%), followed by mTEER (13.0%), ICD implantation (9.9%), TAVR (9.6%), and CABG (7.0%).

Before propensity matching, patients with dysphagia demonstrated significantly different demographic profiles across procedure cohorts. For example, in the CABG cohort, the patients with dysphagia were older (67.9±9.5 versus 65.7±9.9 years; SMD=0.2303), more often female (1607 [31.2%] versus 15 727 [22.8%]; SMD=0.1886), and more likely to be Black (567 [11.0%] versus 5694 [8.3%]; SMD=0.0927) compared with the cohort without dysphagia (Table S2). The disproportionate representation of increasing age, female, and Black patients in the population with dysphagia was seen across ICD, TAVR, and SAVR procedure cohorts but not for mTEER, as there was not a significant difference in age between cohorts (Tables S3 through S6). Across all procedures, patients with dysphagia had significantly greater prevalence of comorbid conditions used for matching, including hypertension, diabetes, hyperlipidemia, obesity, nicotine dependence, alcohol‐related disorders, chronic kidney disease, chronic obstructive pulmonary disease, coronary artery disease, stroke, and heart failure (Tables S2 through S6). The same increased prevalence of comorbid conditions in patients with dysphagia was also seen across all other frailty diagnoses, such as movement abnormalities, malnutrition, sarcopenia, and others (Tables S2 through S6). Propensity matching yielded cohorts of patient pairs with and without dysphagia who underwent CABG (n=5125), ICD implantation (n=4038), TAVR (n=4013), SAVR (n=1955), and mTEER (n=695) (Tables S2 through S6). Post matching, SMD for all demographic and comorbidity variables were<0.1, indicating an acceptable covariate balance.

Mortality Risk in Patients With and Without Dysphagia

The proportional hazards assumption was evaluated for all mortality models and broadly met across the majority of analyses (P>0.05); whereas formal testing yielded minor deviations in certain high‐powered cohorts, visual inspection of the Kaplan–Meier curves confirmed consistent hazards long term, supporting the use of Cox proportional hazards regression. Kaplan–Meier analysis (Table) demonstrated significantly lower 90‐day probability of survival among patients with dysphagia undergoing all cardiovascular surgical procedures except for mTEER (91.7% versus 91.1%; HR, 0.92 [95% CI, 0.65–1.32]). Similarly, 1‐year survival was significantly reduced in dysphagia patients across CABG (89.2% versus 92.4%; HR, 1.42 [95% CI, 1.25–1.63]), ICD implantation (88.3% versus 90.2%; HR, 1.22 [95% CI, 1.07–1.40]), TAVR (86.6% versus 90.3%; HR, 1.42 [95% CI, 1.25–1.63]), and SAVR (85.4% versus 89.5%; HR, 1.39 [95% CI, 1.16–1.67]) procedures. Meanwhile, a significant difference in 1‐year survival post mTEER was not observed between cohorts. One‐year Kaplan–Meier survival curves (Figure 2) confirmed consistently steeper declines in survival among patients with dysphagia, particularly after CABG (χ²=27.4; P<0.0001), TAVR (χ²=27.3; P<0.0001), and SAVR (χ²=12.5; P=0.0004). Relative risk estimates mirrored these findings (Figures 3 and 4), with patients with dysphagia experiencing significantly elevated mortality risk at 90 days and at 1 year for all procedures except mTEER. Specifically, the group with dysphagia had a 43% higher 1‐year mortality risk following CABG (10.3% versus 7.2%; P<0.0001), a 23% increase following ICD implantation (11.3% versus 9.2%; P=0.002), a 42% increase after TAVR (12.9% versus 9.1%; P<0.0001), a 40% increase following SAVR (13.9% versus 9.9%; P=0.0001), and a 15% increase after mTEER (20.6% versus 17.9%; P=0.2007) (Tables S7 through S16).

Table 1.

Survival Probability of Cardiovascular Procedure Patients With and Without Dysphagia

Analysis	No. survivors (survival probability %)		Log‐rank test		Hazard ratio (95% CI)
	Dysphagia	No dysphagia	χ2	P value
CABG 90‐d (n=5152)	4803 (93.1)	4.890 (94.8)	11.702	0.0006*	1.321 (1.126–1.551)
CABG 1‐y (n=5152)	4622 (89.2)	4783 (92.4)	27.447	<0.0001*	1.424 (1.246–1.626)
ICD 90‐d (n=4112)	3918 (95.2)	3974 (96.6)	9.15	0.0025*	1.398 (1.124–1.739)
ICD 1‐y (n=4112)	3648 (88.3)	3733 (90.2)	8.534	0.0035*	1.224 (1.068–1.402)
TAVR 90‐d (n=4066)	3838 (5.6)	3935 (3.2)	25.968	<0.0001*	1.736 (1.400–2.152)
TAVR 1‐y (n=4066)	3540 (86.6)	3696 (90.3)	27.295	<0.0001*	1.423 (1.246–1.625)
SAVR 90‐d (n=1982)	1744 (90.0)	1837 (92.6)	7.154	0.0075*	1.341 (1.081–1.664)
SAVR 1‐y (n=1982)	1706 (85.4)	1785 (89.5)	12.509	0.0004*	1.388 (1.156–1.667)
mTEER 90‐d (n=710)	652 (91.7)	648 (91.1)	0.189	0.6641	0.924 (0.646–1.321)
mTEER 1‐y (n=710)	564 (78.7)	583 (81.3)	1.128	0.2882	1.137 (0.897–1.443)

CABG indicates coronary artery bypass graft; ICD, implantable cardioverter‐defibrillator; mTEER, mitral transcatheter edge‐to‐edge repair; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

^*Indicates significant P values (<0.05).

Figure 2. Kaplan–Meier analysis of survival in cardiovascular surgical procedure patients with and without dysphagia.

Mortality was compared for patients with dysphagia (purple) and without dysphagia (green) after 5 common cardiovascular surgical procedures, including coronary artery bypass graft (A), implantable cardioverter‐defibrillator placement (B), transcatheter aortic valve replacement (C), surgical aortic valve replacement (D), and mitral transcatheter edge‐to‐edge repair (E). CABG indicates coronary artery bypass graft; ICD, implantable cardioverter‐defibrillator; mTEER, mitral transcatheter edge‐to‐edge repair; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

Figure 3. 90‐day risk comparison of complications in cardiovascular surgery patients with and without dysphagia.

CABG indicates coronary artery bypass graft; EGD, esophagogastroduodenoscopy; ICD, implantable cardioverter‐defibrillator; mTEER, mitral transcatheter edge‐to‐edge repair; RR, risk ratio; RT, respiratory tract; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

Figure 4. One‐year risk comparison of complications in cardiovascular surgery patients with and without dysphagia.

CABG indicates coronary artery bypass graft; EGD, esophagogastroduodenoscopy; ICD, implantable cardioverter‐defibrillator; mTEER, mitral transcatheter edge‐to‐edge repair; RR, risk ratio; RT, respiratory tract; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

In contrast, when cohorts were adjusted for frailty markers, survival was reduced only in patients with dysphagia at 90 days following TAVR (94.5% versus 95.6%; HR, 1.27 [95% CI, 1.04–1.55]; χ²=5.3; P=0.02) and at 1 year following CABG (89.35% versus 90.7%; HR, 1.14 [95% CI, 1.00–1.29]; χ²=4.1; P=0.04) and TAVR (86.9% versus 88.8%; HR, 1.19 [95% CI, 1.05–1.35]; χ²=7.0; P=0.008) (Table S17, Figure S1), RRs reflecting the same trend (Figures S2 and S3).

Postoperative Complication Risk Comparison in Patients With and Without Dysphagia

Patients with dysphagia demonstrated significantly higher risk for developing stroke, infectious pneumonia, and hypoxemia at both 90 days and 1 year postoperatively across all cardiovascular procedures (Tables S7 thorugh S16, Figures 3 and 4). For example, 90‐day stroke risk was substantially higher among patients with dysphagia following CABG (9.5% versus 6.0%; RR=1.60; P<0.0001), ICD implantation (7.0% versus 4.7%; RR=1.50; P<0.0001), TAVR (8.0% versus 6.2%; RR=1.29; P=0.002), SAVR (12.8% versus 8.9%; RR=1.44; P<0.0001), and mTEER (7.9% versus 4.8%; RR=1.65; P=0.002). Significantly increased risk of all complications remained after adjustment for frailty markers at 90 days following all procedures except for risk of infectious pneumonia or intubation following mTEER and risk of stroke following TAVR (Figure S2). Differences in stroke, infectious pneumonia, and hypoxemia risk persisted at 1 year across all procedures (Figure S3).

In addition to elevated stroke risk, dysphagia was associated with significantly increased rates of intubation at 1 year across all procedures. Aspiration pneumonia was also significantly more common at 1 year for all procedures except mTEER. Further, foreign body aspiration was significantly more frequent at 1 year in patients with dysphagia following CABG (1.8% versus 0.4%; RR, 3.96; P<0.0001), ICD implantation (2.2% versus 0.3%; RR, 7.50; P<0.0001), TAVR (1.9% versus 0.4%; RR, 4.39; P<0.0001), and SAVR (2.1% versus 0.6%; RR, 3.81; P<0.0001), shown in Figures 3 and 4. Finally, the need for esophagogastroduodenoscopy was markedly elevated among patients with dysphagia at 90 days following CABG (3.2% versus 0.3%; RR, 9.71; P=0.0001) and SAVR procedures (4.0% versus 0.5%; RR, 7.90; P<0.0001), with significant differences also observed at 1 year. Trends in postprocedural risk of foreign body aspiration, aspiration pneumonia, intubation, and esophagogastroduodenoscopy remained largely consistent and significant even after adjusting for markers of frailty for all procedures except mTEER (Tables S18 through S27, Figures S2 and S3).

DISCUSSION

In this large, multicenter cohort of adults undergoing common cardiovascular surgical procedures, a preoperative diagnosis of dysphagia was independently associated with significantly higher 90‐day and 1‐year postoperative mortality. Elevated risk was evident across CABG, ICD implantation, TAVR, and SAVR, with dysphagia linked to a 40% to 60% increase in short‐term mortality relative to matched controls. Dysphagia was also associated with substantially higher postoperative complication rates, including approximately twice the risk of stroke and 3 to 6 times the risk of aspiration pneumonia, as well increased incidence of infectious pneumonia, hypoxemia, and intubation. Collectively, these findings identify dysphagia as a clinically relevant prognostic factor in cardiovascular surgical populations, regardless of the procedure type.

The mechanisms underlying these associations likely reflect a convergence of biological frailty, neurogenic dysfunction, and procedural stress. Dysphagia reflects underlying physiologic vulnerability capturing features of frailty, such as sarcopenia, malnutrition, and diminished cardiopulmonary reserve, all of which impair recovery from major surgery. ¹⁶ , ¹⁷ , ¹⁸ Sarcopenic oropharyngeal musculature and loss of coordination between swallowing and respiration compromising airway protection can lead to silent aspiration and subsequent pulmonary sequelae. The resulting cascade, along with the combination of microaspiration, bacterial inoculation, and systemic inflammation, offers a plausible explanation for the excess risk for aspiration pneumonia, hypoxemia, and intubation observed in our study. Neurologic comorbidities, including prior stroke, exacerbate this risk by impairing cough reflex, delaying pharyngeal clearance, and diminishing respiratory drive. ¹⁹ , ²⁰ Nutritional deficiencies from chronic swallowing difficulty further impairs wound healing due to compromised immunity and increased susceptibility to infection. Beyond these direct pathways, dysphagia also acts as an integrative biomarker of vulnerability, reflecting a cumulative burden of multimorbidity, including cerebrovascular, pulmonary, and degenerative disease, which heightens procedural risk across surgical contexts. ²¹ Interestingly, our study identified dysphagia as more common among older patients and minority groups, including women and Black patients, populations historically associated with higher comorbidity burdens. Although this further supports the use of dysphagia as a biomarker of frailty, additional research is needed to confirm these associations across broader and more demographically diverse cohorts.

Given the substantial overlap between dysphagia and other frailty markers, an important question is whether the observed associations reflect swallowing dysfunction itself or simply the clustering of advanced comorbid illness. To explore this, we performed an expanded sensitivity analysis incorporating 10 additional frailty markers. Although adjustment for these factors modestly attenuated mortality signals in certain cohorts, the associations between dysphagia and adverse outcomes, especially respiratory complications, remained robust. Although adjustment for these factors modestly attenuated mortality signals in certain cohorts, the persistence of elevated risk for aspiration pneumonia, hypoxemia, and reintubation suggests that dysphagia itself confers a direct and biologically plausible postoperative risk in addition to serving as a proxy for generalized illness severity.

In our study, the magnitude of risk associated with dysphagia varied modestly by procedure type, as did the relative prevalence of other frailty markers. Patients undergoing open operations such as CABG and SAVR experienced substantial increases in mortality and respiratory complications, likely due to longer anesthesia duration, cardiopulmonary bypass use, and extended postoperative ventilation, which exacerbate aspiration vulnerability during early recovery. This is clearly reflected in the Kaplan–Meier survival curves for CABG and SAVR patients, which demonstrate a distinct divergence in mortality risk beginning approximately 30 days post procedure. Although the immediate perioperative period carries inherent risk for all patients, the widening gap after the first month suggests that the impact of dysphagia may extend into the subacute recovery phase. In these more invasive procedures, the cumulative impact of persistent microaspiration and nutritional depletion may hinder the typical recovery trajectory, preventing patients with dysphagia from reaching the same stability as patients without dysphagia once the initial surgical stress has subsided. This prognostic value is particularly striking in the relatively healthier, lower‐risk populations that cardiothoracic surgeries are preferentially recommended for. In these patients, where the overall burden of frailty diagnoses is far lower, dysphagia may be a stronger predictor of poor outcomes.

Dysphagia remained a significant predictor of mortality even in less invasive procedures such as ICD implantation and TAVR, the latter of which has shown good outcomes for high‐risk patients with more comorbid diseases. In contrast, mortality risk following mTEER was similar between groups at both time scales, which may be related to physicians advising against mTEER in dysphagia patients due to the perceived higher risk with significant dependence on intraprocedural transesophageal echocardiography or a high baseline frailty level among mTEER patients irrespective of a dysphagia diagnosis. Nevertheless, higher risk of other outcomes like stroke and intubation in the mTEER cohort with dysphagia points to ongoing impact from frailty progression, nutritional depletion, and aspiration‐related complications. Previous work similarly demonstrates that frailty indicators predict adverse outcomes across both open and transcatheter interventions, suggesting that physiologic reserve, rather than procedural invasiveness, governs postoperative health. ²² , ²³ , ²⁴ Taken together, these findings suggest that dysphagia functions as an integrative marker of frailty and diminished functional reserve and is a key determinant of surgical vulnerability rather than the degree of procedural invasiveness.

Prior literature supports the association between dysphagia and poor outcomes in medically complex populations, including heart failure. ²⁵ Studies have linked oropharyngeal dysphagia to aspiration pneumonia, malnutrition, prolonged hospitalization, and mortality in older adults and patients with neurologic impairment. ¹⁶ , ²¹ , ²⁶ , ²⁷ Prospective cohorts have also demonstrated that dysphagia predicts readmission and respiratory infections in hospitalized older patients and correlates with sarcopenic decline in ambulatory settings. ²⁸ , ²⁹ In cardiac surgery, frailty has been consistently associated with increased mortality, readmission, and health care resource use. In a large national cohort of >240 000 patients, Miles et al. found that frailty independently predicted adverse outcomes, including higher in‐hospital mortality, readmission rates, and health care costs after both TAVR and SAVR, highlighting its systemic impact across procedural approaches. ³⁰ Similarly, Lin et al. identified age, malnutrition, polypharmacy, and poor oral hygiene as key contributors to dysphagia risk, highlighting the bidirectional link between frailty and dysphagia in late‐life vulnerability. ²¹ Similar findings in TAVR cohorts have extended these findings, identifying frailty, malnutrition, and reduced muscle mass as predictors of 1‐year mortality and poor functional recovery. ²³ Despite this evidence, few studies have evaluated dysphagia as a measurable correlate of frailty or quantified its prognostic impact across multiple cardiovascular procedures. The present study addresses this gap by demonstrating that dysphagia, an observable and clinically meaningful condition, captures the physiologic vulnerability traditionally described by complex frailty scales, offering an efficient and actionable bedside indicator of risk.

Recognition of dysphagia as a cardiovascular surgical risk factor has several practical implications. Incorporating swallow screening into standard preoperative risk assessments, alongside Society of Thoracic Surgeons and EuroSCORE evaluations, could improve identification of high‐risk patients. ³¹ Brief validated tools such as the Eating Assessment Tool‐10 provide a simple, patient‐reported method to detect swallowing difficulty with minimal resource burden in both inpatient and outpatient settings. ³² The use of structured screening could facilitate early referral for instrumental evaluation, prehabilitation, or nutritional optimization. Perioperative measures such as aspiration precautions, individualized extubation protocols, early mobilization, and multidisciplinary involvement from speech‐language pathologists, respiratory therapists, and dietitians may further mitigate pulmonary complications. Programmatic adoption of dysphagia screening as a quality metric could enhance risk detection and support standardization in surgical care pathways.

The present study has notable strengths, including its large sample size, usage of a multicenter real‐world database, and inclusion of diverse cardiovascular procedures encompassing both open and transcatheter approaches. Rigorous propensity score matching also reduced baseline imbalances and improved internal validity. This study is the first large‐scale, multiprocedure analysis to quantify the prognostic impact of dysphagia across common cardiovascular interventions, integrating a clinically observable condition into perioperative risk stratification. By linking a clinically accessible diagnosis to postoperative outcomes, the study supports the integration of functional assessment into contemporary surgical risk models.

Nevertheless, several limitations merit consideration. First, the analysis relied on administrative coding, which may result in underascertainment of dysphagia and complications, and lacked granular detail on dysphagia subtype, severity, instrumental testing, procedure‐specific risk scores such as Society of Thoracic Surgeons and EuroScore, and patient‐reported outcomes, limiting assessment of gradations in risk or recovery trajectories. Moreover, the database analytics platform is limited to 1:1 matching and does not support formal competing risk modeling for matched cohorts. Importantly, identification of dysphagia also depended on recorded diagnoses; as the methods used to establish the diagnosis are unknown, it is possible that not all patients were systematically screened. As a result, undiagnosed dysphagia in some patients classified as without dysphagia may have been present, which would likely bias effect estimates toward the null, thereby underestimating the true impact of dysphagia. In addition, although propensity matching and additional sensitivity analyses incorporating frailty‐related variables were performed, residual confounding remains possible as matching adjusts only for measured covariates and cannot account for unmeasured or imperfectly captured factors. Patients with dysphagia were older and frailer at baseline, and differences in socioeconomic status, health care access, comorbidity severity, nutrition support, and adherence to postprocedural oral medications may have influenced outcomes. Similarly, although we ensured dysphagia diagnoses preceded the index procedures, we did not impose a minimum latency period; although a multimonth gap could address concerns of reverse causality, doing so in this high‐acuity surgical population would introduce substantial selection and survivor bias by excluding the most urgent patients. Our findings should therefore be interpreted as associative rather than causal. But despite these constraints, the consistency and magnitude of observed associations across procedures and end points support the clinical relevance of dysphagia as an important predictor of surgical risk.

CONCLUSIONS

Preoperative dysphagia is independently associated with significantly increased short‐term mortality and respiratory complications following common cardiovascular surgical procedures. Elevated risk was observed at both 90 days and 1 year postoperatively across a range of interventions, including coronary revascularization and valve‐related therapies. The presence of dysphagia also correlated with a higher incidence of hypoxemia, aspiration and infectious pneumonia, and postoperative intubation, suggesting a broader vulnerability to perioperative pulmonary compromise. Recognition of dysphagia as a surrogate marker of frailty and diminished physiologic reserve provides an opportunity to enhance perioperative risk stratification. Integration of validated dysphagia screening tools into preoperative workflows may allow for early identification of high‐risk patients and facilitate targeted multidisciplinary interventions. Further prospective studies are needed to confirm the prognostic significance of dysphagia and to determine whether systematic screening and early management improve outcomes in cardiovascular surgical populations.

Sources of Funding

Funding for this work was supported by the National Institutes of Health/National Heart, Lung, and Blood Institute R01HL162851 (Monica Mukherjee), US Department of Defense PR231648 (Monica Mukherjee).

Disclosures

None.

Supporting information

Figures S1–S3

Tables S1–S27