They’re a high-risk population with few options. But heart failure patients with left ventricular assist devices who are appropriate candidates can successfully undergo sleeve gastrectomy bariatric surgery, a new study based on experience at Cleveland Clinic demonstrates. The rapid weight loss associated with the procedure can help patients qualify for the transplant list and, in some cases, improve their heart function to a point that obviates the need for the LVAD or a heart transplant altogether.
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“There is very little data supporting the sleeve as a bridge to heart transplant. We want to make sure people know that, in the right hands, at the right center and in the right patient, it can be done safely,” says Stacy Brethauer, MD. “For carefully selected patients, the benefits will outweigh the risks.”
Dr. Brethauer and colleagues reviewed the experience of four women and one man with end-stage heart failure previously placed with LVADs at Cleveland Clinic. Median preoperative body mass index was 41.6 kg/m2 (range, 36.7-56.7) and median age was 38 years. Etiologies for heart failure included ischemic cardiomyopathy, two with non-ischemic non-idiopathic cardiomyopathy and one with postpartum cardiomyopathy. New York Heart Association (NYHA) classifications before surgery ranged from 2 to 4.
The patients also presented with a number of other conditions, including hypertension, sleep apnea, atrial fibrillation, coronary artery disease, dyslipidemia and diabetes mellitus. All participants were being bridged for heart transplantation.
After a median 37 months after LVAD implantation, participants underwent sleeve gastrectomy at Cleveland Clinic between 2013 and 2015. The findings were presented at the American Society for Metabolic and Bariatric Surgery Annual Meeting/Obesity Week 2016.
A feasible option
“The sleeve gastrectomy is a good operation for these patients. It tends to have fewer complications than the bypass procedures and offers rapid weight loss,” Dr. Brethauer says. These patients remain high risk, however. Heart failure is a known risk factor for abdominal surgery and is associated with limited physiologic reserve. Anticoagulation therapy and the assist device itself also increase the challenges — sometimes the LVAD drivelines are in the surgical field, for example. Postoperative bleeding secondary to anticoagulation that occurred in one patient on the second postoperative day was medically managed.
No one died perioperatively. However, one patient died at 22 months secondary to sepsis associated with the LVAD.
Median follow up was 12 months. At one year, median BMI decreased to 29.8kg/m2 (range, 25.6-31), representing 71 percent excess weight loss. At the same time, median left ventricular ejection fraction increased from 19 percent to 23 percent.
Cardiologists and cardiac surgeons refer many heart failure patients to Cleveland Clinic for bariatric surgery because “they recognize — and there is a lot of data to support this — that heart function and cardiovascular risk improves as the weight decreases,” Dr. Brethauer says. “Keep sending patients you think are appropriate and we’ll continue taking good care of them and getting them healthier, so you can manage their heart disease more effectively.”
More research needed
A prospective study in the future could assess more detail about how the weight loss improves physiology and heart function. “Ultimately, as we get more and more of these patients, we can tell how many successfully undergo transplant … and how many of them actually improve to the point where they don’t need transplants.”
Laparoscopic sleeve gastrectomy results in acceptable perioperative morbidity, weight loss and improves their candidacy for heart transplantation. “The discussion regarding weight loss surgery can be difficult but these patients should at least be offered the surgery if they are a candidate. It can be pretty remarkable in terms of turning their lives around.”