Heart failure (HF) has been linked to adverse postoperative outcomes, yet contemporary evidence in bariatric surgery remains limited. A retrospective analysis of the 2023–2024 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database published in the Surgery for Obesity and Related Diseases evaluated 30-day outcomes following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in patients with versus without HF.
Patients undergoing SG (n=231,243) and RYGB (n=96,546) were included. A 4:1 propensity score matching approach was applied, balancing 24 preoperative characteristics to compare outcomes between HF and non-HF cohorts. Multivariate logistic regression analyses were conducted to identify independent predictors of postoperative complications for both procedures.

Among patients undergoing SG, those with HF experienced higher rates of mortality, cardiac and pulmonary complications, unplanned intensive care unit admissions, readmissions, interventions, nonhome discharge, and postoperative bleeding (P<0.05). In the RYGB cohort, HF was associated with increased mortality, pulmonary and renal complications, unplanned intensive care unit admissions, emergency visits, readmissions, and interventions (P<0.05). 
HF emerged as the strongest independent predictor of 30-day mortality following SG (odds ratio [OR]: 4.88; 95% confidence interval [CI]: 2.88–8.27; P<0.001) and the second strongest predictor following RYGB (OR: 2.90; 95% CI: 1.37–6.14; P=0.005).

HF was consistently associated with increased postoperative morbidity and mortality across both procedures. Preoperative cardiac optimization is strongly advised in patients with HF undergoing bariatric surgery.