Multiple Sclerosis Does Not Appear to Worsen In-Hospital Outcomes After Cardiovascular Surgery, but Routine Home Discharge Is Less Common

Highlights

In a nationwide US analysis of 1,766,170 cardiovascular surgery admissions from 2016 to 2022, only 3,605 involved patients with multiple sclerosis, underscoring how limited the evidence base has been for this population.

After balancing-score matching, multiple sclerosis was not associated with significantly higher in-hospital mortality or a higher overall complication burden after coronary artery bypass grafting, valve surgery, aortic surgery, or combined procedures.

Most postoperative complications, including stroke, acute kidney failure, venous thromboembolism, pneumonia, sepsis, bleeding, prolonged ventilation, and pacemaker requirement, occurred at similar rates in patients with and without multiple sclerosis.

The main clinically relevant difference was post-acute disposition: patients with multiple sclerosis were significantly less likely to be discharged routinely home, suggesting a greater rehabilitation or care-coordination burden even when immediate surgical outcomes are comparable.

Background and Clinical Context

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system characterized by inflammatory demyelination, neuroaxonal injury, and progressive disability in a subset of patients. Although MS is classically discussed in neurological terms, its implications extend well beyond relapse management and disease-modifying therapy. Patients with MS often accumulate multimorbidity, mobility limitations, autonomic dysfunction, mood disorders, and chronic respiratory or endocrine comorbidities that can complicate major surgery.

Cardiovascular disease has become increasingly relevant in MS care. Epidemiologic studies suggest that patients with MS may experience higher rates of myocardial infarction and heart failure than the general population. Several mechanisms may contribute, including chronic systemic inflammation, reduced physical activity, treatment-related effects, shared vascular risk factors, and barriers to preventive care. In parallel, autonomic dysfunction in MS can affect heart rate variability, blood pressure regulation, and thermoregulation, raising plausible concerns about perioperative hemodynamic instability.

These concerns are especially pertinent in cardiovascular surgery, where perioperative stress is substantial and postoperative complications are often driven by tightly coupled neurologic, hemodynamic, renal, and pulmonary physiology. Yet clinicians have had little empirical guidance on how patients with MS fare after major cardiac operations. The present study addresses that gap by examining nationwide US in-hospital outcomes after cardiovascular surgery in patients with MS.

Study Design

This investigation was a cross-sectional study using the National Inpatient Sample, a large US administrative database designed to generate nationally representative hospitalization estimates. The authors identified adults who underwent major cardiovascular surgery between 2016 and 2022. Eligible procedures included coronary artery bypass grafting, valve surgery, aortic surgery, and combined cardiovascular operations.

The exposure of interest was a diagnosis of multiple sclerosis. The primary goal was to compare in-hospital outcomes between patients with and without MS during the index surgical admission. Because patients with MS differ systematically from other cardiac surgical patients in age, sex, and comorbidity profile, the investigators used a balancing-score matched cohort to reduce measured confounding.

The main outcomes included in-hospital mortality, a composite complication endpoint, individual postoperative complications, length of stay, hospitalization costs, and discharge disposition. Data analysis was performed in November 2025.

Population and Baseline Characteristics

The study included records for 1,766,170 patients undergoing cardiovascular surgery nationwide. Among these, 3,605 had MS and 1,762,565 did not. Even in such a large database, the number of patients with MS was relatively small, which itself highlights how uncommon this clinical scenario is and why prior single-center experience has likely been sparse.

Before matching, the MS cohort had a distinct clinical profile. Patients with MS were younger, with a median age of 63 years compared with 67 years in those without MS. Women represented 56% of the MS cohort versus 28% of the non-MS cohort, consistent with the known female predominance of MS.

Comorbidity patterns also differed meaningfully. Patients with MS had higher frequencies of chronic lung disease, depression, hypothyroidism, paralysis, psychosis, and valvular disease. These features are clinically relevant because they may influence both operative risk and postoperative recovery. Depression and psychosis can affect postoperative participation and discharge planning. Paralysis and mobility impairment may not increase traditional surgical complications directly but can substantially alter rehabilitation needs, transfer safety, and the feasibility of a routine home discharge.

Key Findings

Mortality

In the matched cohorts of 3,530 patients, in-hospital mortality did not differ significantly between patients with and without MS. Mortality occurred in 70 patients with MS, or 2.0%, compared with 130 patients without MS, or 3.7%, with a P value of .05. Statistically, this result sits at the threshold of significance and should be interpreted cautiously. Importantly, there is no evidence here that MS confers an excess in-hospital mortality signal after cardiovascular surgery. If anything, the point estimates trend toward lower mortality in the MS group, though this should not be overinterpreted as a protective effect.

Composite and Individual Complications

The prevalence of the composite complication endpoint was nearly identical between groups: 50% in patients with MS and 51% in matched patients without MS, with no significant difference. This finding is central to the paper’s message. Concerns that MS-related autonomic dysfunction or neurological vulnerability might broadly amplify perioperative risk were not supported at the level of observed inpatient complications.

The similarity extended across a wide range of individual outcomes. Rates were comparable for stroke, acute kidney failure, pulmonary embolism, deep vein thrombosis, gastrointestinal bleeding, non-gastrointestinal bleeding, prolonged mechanical ventilation, tracheostomy, pneumonia, surgical site infection, sepsis, blood transfusion, pericardial effusion, fluid overload, and pacemaker implantation.

From a practical standpoint, this is reassuring for heart teams and anesthesiologists. The study suggests that major cardiovascular surgery can be delivered to patients with MS without a clear increase in immediate inpatient morbidity, provided usual contemporary perioperative care is available.

Length of Stay and Costs

Resource utilization was also similar between groups. Median length of stay was 8 days in both cohorts, with an interquartile range of 6 to 12 days and no significant difference. Median hospitalization cost was likewise comparable: $41,285 in the MS cohort versus $40,328 in those without MS, again without a significant difference.

These findings argue against a major hidden inpatient burden attributable to MS during the surgical admission itself. At least within the limits of administrative data, patients with MS did not require materially longer hospitalization or greater inpatient spending.

Discharge Disposition

The most important between-group difference emerged after the acute postoperative phase. Routine home discharge occurred in only 28% of patients with MS compared with 36% of matched patients without MS, a statistically significant difference with P less than .001.

This result is clinically intuitive and arguably the most actionable observation in the study. A patient with MS may recover from surgery without excess mortality or classic postoperative complications yet still be less able to return directly home because of baseline neurologic disability, gait impairment, fatigue, spasticity, deconditioning, bladder dysfunction, caregiver limitations, or the need for inpatient rehabilitation or skilled nursing support. The discharge signal therefore likely reflects functional reserve and care needs more than surgical failure.

Clinical Interpretation

This study offers a useful corrective to assumptions that neurological disease necessarily translates into worse short-term cardiac surgical outcomes. MS is a complex disease, but the data suggest it should not be viewed as an automatic marker of prohibitive operative risk for coronary, valve, or aortic surgery.

That said, equivalent in-hospital outcomes do not mean perioperative care can be routine. Patients with MS may still require individualized planning. Preoperative review should include baseline neurological function, mobility status, autonomic symptoms, swallowing or respiratory issues, current disease-modifying therapy, corticosteroid exposure, and psychosocial support. Perioperative teams should also remain attentive to temperature management, delirium prevention, bowel and bladder care, venous thromboembolism prevention, and early mobilization. Even if complication rates are not higher at the population level, these domains remain important to recovery quality.

The lower rate of routine home discharge supports a multidisciplinary model. Involving neurology, physical therapy, occupational therapy, case management, social work, and where appropriate rehabilitation medicine may improve transitions of care. For many patients, the key determinant of a successful postoperative course may be whether discharge planning starts before surgery rather than after it.

Strengths of the Study

The principal strength is scale. National Inpatient Sample data allowed the authors to study a rare but clinically important subgroup across several major cardiovascular procedures. This improves external relevance beyond what a single tertiary-center series could provide.

The use of a balancing-score matched design is another advantage. Because patients with MS differ systematically from the broader cardiac surgery population, unadjusted comparisons would have been difficult to interpret. Matching improves comparability on measured characteristics and strengthens the inference that outcomes are broadly similar.

The breadth of outcomes is also helpful. Rather than focusing only on mortality, the authors evaluated a wide postoperative complication profile, resource use, and discharge status, providing a more clinically complete picture.

Limitations and Cautions

As with all administrative database studies, several limitations matter. First, the analysis is observational and cross-sectional, so causality cannot be established. Residual confounding is likely even after matching, especially for variables not well captured in billing data.

Second, disease-specific MS details were unavailable. The database cannot reliably distinguish relapsing-remitting from progressive disease, quantify neurologic disability, identify recent relapses, or capture severity of autonomic dysfunction. These factors may be highly relevant to perioperative risk and discharge disposition.

Third, procedural granularity is limited. Important operative details such as urgency, cardiopulmonary bypass time, surgical complexity, left ventricular function, frailty, and surgeon or center volume may not be fully represented. Similarly, inpatient data cannot evaluate postdischarge outcomes such as 30-day mortality, readmission, rehabilitation success, or longer-term neurological status.

Fourth, the borderline P value for mortality should be interpreted with restraint. The absence of a statistically significant difference does not prove equivalence in the strict methodological sense. Rather, it supports the practical conclusion that no clear excess in-hospital mortality was detected.

Implications for Practice and Policy

For cardiac surgeons, anesthesiologists, intensivists, and neurologists, the takeaway is reassuring but nuanced. MS alone should not necessarily dissuade referral for indicated cardiovascular surgery. Decisions should remain driven by surgical indication, overall frailty, cardiovascular risk, neurological function, and patient goals.

For hospitals and health systems, the discharge findings may be the more important operational message. Patients with MS may benefit from proactive discharge planning, early therapy consultation, caregiver assessment, and coordination with outpatient neurology and rehabilitation services. In value-based care environments, attention to these transitions could reduce downstream institutionalization or readmission risk, even if the index hospitalization looks similar on standard metrics.

For researchers, the next step is more granular outcome work. Prospective or registry-based studies should examine how MS phenotype, disability level, disease-modifying therapy, autonomic dysfunction, and rehabilitation access influence perioperative and longer-term outcomes after cardiac surgery.

Conclusion

This large nationwide study suggests that multiple sclerosis is not associated with higher in-hospital mortality, complication rates, length of stay, or hospitalization costs after major cardiovascular surgery. The important exception is discharge disposition: patients with MS are less likely to go directly home after surgery, pointing to a greater functional and transitional-care burden rather than excess acute surgical harm.

In practical terms, the findings support offering cardiovascular surgery to appropriately selected patients with MS while emphasizing multidisciplinary perioperative planning. The challenge may be less about surviving the operation and more about optimizing recovery pathways, rehabilitation, and postdischarge support.

Funding and ClinicalTrials.gov

The abstract does not report a funding source. No ClinicalTrials.gov registration applies to this cross-sectional analysis of the National Inpatient Sample database.

Citation

Diz Ferre JL, Zhou G, Cabulong A, Deschamps J, Koroukian SM, Schiltz N, Sajatovic M, Bakaeen F, Gillinov M, Soltesz EG. Outcomes of Cardiovascular Surgery in Patients With Multiple Sclerosis. JAMA Surgery. 2026-06-10. PMID: 42268624. Available at: https://pubmed.ncbi.nlm.nih.gov/42268624/