Abstract

Introduction: About 25% of patients suffering end stage heart failure (ESHF) are obese. BMI>40 prevents patients from receiving an organ graft because morbid obesity (MO) dramatically increases mortality after heart transplantation (HTx). Moreover, MO (BMI>40) increases the risk of thromboembolic events by 20%. The treatment of ESHF in obese patients must include the treatment of their obesity.

Bariatric surgery (BS) is the most effective treatment for MO, but has prohibitive surgical mortality in ESHF patients. One strategy is to first implant a Left Ventricular Assist Device (LVAD) to provide hemodynamic stability during BS and eventually reduce patient’s BMI to values compatible with HTx (bridge-to-candidacy approach). However, stopping the anticoagulation for BS increases the risk of LVAD thrombosis and/or thromboembolic events, particularly in presence of MO. We report the therapeutic pathway we applied to solve this challenging situation.

Method: A 54 years old man, former smoker, with a BMI of 43.8 kg/m² and sleep apnea syndrome, suffered from ESHF due to ischemic (LAD occlusion) and rhythmic cardiomyopathy (non valvular atrial fibrillation) with CHA2DS2- VASC score 5. Left ventricle ejection fraction was 20%. Mean pulmonary pressure was 35 mm Hg and cardiac index was 2.0 l/min/m². His BMI was the only contraindication to HTx. Our institutional Heart Failure Team decided to implant a continuous flow LVAD to improve patient’s hemodynamic condition and then perform a sleeve gastrectomy (SG).

Results: LVAD implant (Abbott HeartMate 3) was performed under CPB (75 min) using a minimal invasive approach through an upper ministernotomy and a left anterior hemi thoracotomy. The operation and post-operative phase were uneventful. The patient was extubated less than 12 hours after the surgery and left ICU on postoperative day (POD) 3. Clopidogrel and anti-vitamin K treatment were introduced on POD 3. Despite nutritional management and rehabilitation, the patient’s weight increased by 7 kg during the first postoperative months. Thus, it was decided to perform SG using a laparoscopic approach 10 months after LVAD implant. Sintrom was suspended 3 days before the procedure and replaced by prophylactic IV Heparin (anti-Xa<0.1). Sintrom was reintroduced on POD 3. The operation was uneventful despite three previous abdominal open surgeries, with no need of laparotomy conversion. The patient was discharged at POD 10. Patient lost 22 Kg in the first 3 months after SG (BMI<35), he is now listed to HxT.

Conclusion: LVAD followed by BS represents an effective therapeutic strategy to make ESHF obese patients eligible for HTx. New generation LVADs make the management of anticoagulation treatment safer than ever even in patients at high risk for thromboembolic complications.

Keywords: Left ventricular assist device bariatric surgery; Laparoscopic sleeve gastrectomy; End stage heart failure; Heart transplant