Outcomes After Bariatric Surgery In Patients With Ventricular Assist Devices: Systematic Review And Individual Participant Data Meta-analysis

Abstract

Background: Body mass index (BMI) 35 kg/m2 is a major contraindication for heart transplantation (HT). Consequently, many patients who would otherwise be good HT candidates require ventricular assist devices (VADs) as destination therapy. Furthermore, some HT candidates who initially had a BMI < 35 kg/m2 but gained weight during VAD support may lose their candidacy. All evidence for a potential role of bariatric surgery (BS) in obese VAD patients comes from small cohorts and case reports which makes its interpretation challenging. Methods: A systematic search was performed in ClinicalTrials.gov, Cochrane, Embase and PubMed. Other sources screened included Google Scholar, meeting proceedings, journal sites, and references cited in included studies. Selected subjects were obese, adult patients with VADs who underwent BS and had follow-up BMI data. Results: Twelve references with 29 patients (age 41.9 [§ 12.2] years, 63.6% male) were included. The baseline BMI was 45.2 (§ 6.7) kg/m2 . Most patients (82.8%) underwent sleeve gastrectomy while 17.2% received Roux-en-Y gastric bypass. Median follow-up was 24 (12-30) months. Eleven (39.3%) patients had postoperative adverse events after BS. Among the 23 patients with documented listing status (listed vs. not listed for HT) after BS, 78.3% lost enough weight and were listed for HT. Thirteen patients underwent HT 14.4 (§ 7) months after BS, and three patients had myocardial recovery with VAD explantation after weight loss. Twenty-two of 28 (78.6%) patients achieved the composite outcome of BMI < 35 kg/m2 /OHT/listing for OHT/myocardial recovery at 11 (3-17) months. Figure 1 shows a Kaplan-Meier curve for the composite outcome. There were no deaths during the HTfree 1-year follow-up. Conclusions: In VAD patients who are not HT candidates due to obesity, BS may allow for enough weight loss to improve their candidacy for HT or even achieve myocardial recovery. Although there were no deaths reported during HTfree 1-year follow-up, there was a high rate of adverse events during the postoperative period. However, the rate of these events may decrease as programs become more experienced with BS in VAD patients.