The Use of Bariatric Surgery in Patients with Left Ventricular Assist Devices to Expedite Heart Transplant Candidacy

Introduction Obesity is a common comorbidity which can complicate management of advance heart failure (AHF) and preclude heart transplant. The use of bariatric surgery has been studied as a weight-loss therapy in AHF patients. The left ventricular assist device (LVAD) has been used as either destination therapy or bridge to candidacy in these obese AHF patients. Methods We reviewed bariatric surgery in LVAD patients who were implanted as bridge to candidacy as a means to expedite candidacy for cardiac transplant. A retrospective chart review was performed on LVAD patients to identify those who underwent bariatric surgery. Clinical data were collected at baseline prior to bariatric surgery and 3 months post-surgery. Data collected included age, etiology of cardiomyopathy, body mass index (BMI), bariatric procedure performed, complications, time to transplant candidacy and ultimate clinical outcome. Three patients (2 female), with a mean age of 51 (range 50-53) were reviewed. All 3 patients had a diagnosis of non-ischemic cardiomyopathy. The average baseline BMI was 39 kg/m2 (range 37- 42). Laparoscopic sleeve gastrectomy was performed on all three patients. Results One patient had significant postoperative bleeding requiring multiple transfusions and reversal of anticoagulation. Anticoagulation was interrupted multiple times during the hospitalization due to bleeding and labile INR levels. A rise in LDH was noted during the hospitalization. One-month post discharge from bariatric surgery the patient was admitted for suspected pump thrombosis with power spikes. She was discharged home after intravenous anticoagulation with baseline LDH and power levels without any neurologic or hemodynamic sequelae. The 3-month average BMI and total weight loss percentage was 34 kg/m2 (range 30 - 38) and 12.5% (range 3.3-20.2%), respectively. All three patients were listed for transplantation with an average time to transplant candidacy of 116 days (range 105-123) following bariatric surgery. Two of the 3 patients received a heart transplant at an average of 145 days (range 130-161) from bariatric surgery. The other patient developed an intracranial hemorrhage 476 days following bariatric surgery and ultimately deemed not a transplant candidate. Conclusion Our retrospective cohort analysis confirms the efficacy of bariatric surgery as a weight loss therapy in obese LVAD patients as a method to shorten time to transplant candidacy. Postoperative bleeding must be managed carefully in consideration of the risk of prolonged cessation of anticoagulation.