Efficacy of bariatric intervention as a bridge to cardiac transplant

Bariatric surgery in patients with ventricular assist devices: a matched analysis of MBSAQIP

BACKGROUND

Patients with obesity and heart failure managed with ventricular assist devices (VADs) are a medically complex population who could benefit from metabolic and bariatric surgery (MBS), but are often considered prohibitively high risk.

OBJECTIVES

We wished to report the outcomes following MBS in patients with VADs in a contemporary North American cohort.

SETTING

Accredited MBSAQIP centers in United States and Canada in 2022.

METHODS

We used the 2022 MBSQIP participant user file (PUF) to identify all patients who had a preoperative ventricular assist device. We reported the baseline characteristics, hospitalization course, 30-day complications, and weight loss outcomes. We performed 1:1 nearest neighbor Mahalanobis distance matching without replacement to identify patients with similar comorbidities, and used g-computation to estimate the independent effect of VAD therapy on key outcomes.

RESULTS

Of the 120 patients undergoing MBS with a history of VAD, 78 underwent sleeve gastrectomy and 17, Roux-en-Y gastric bypass. The median postoperative length of stay was 2 days, and with 119 patients surviving to hospital discharge, the overall 30-day risk of death was .8%. There were no recorded pulmonary embolism, stroke, cardiac arrest, or myocardial infarction events. Compared to their matched counterparts, VAD patients had an increased risk of length of stay >7 days (risk ratio 1.40, 95% CI: .91-2.14) and required more units of blood transfusion (mean difference .19, 95% CI: .06-.32). VAD therapy was not statistically significantly associated with an increased risk of death (risk ratio 1.04, 95% CI .76-1.42).

CONCLUSIONS

Early outcomes after bariatric surgery in patients with VADs suggest feasibility and safety. Larger studies with well-defined selection criteria and longer term follow up are needed to confirm these results.

Adjuvant and Neo-Adjuvant Anti-Obesity Medications and Bariatric Surgery: A Scoping Review

PURPOSE OF REVIEW

To comprehensively summarize the current body of literature on the topic of adjuvant and neoadjuvant pharmacotherapy used in combination with bariatric surgery.

RECENT FINDINGS

Anti-obesity medications (AOMs) have been used since the mid-1900s; however, their use in combination with bariatric surgery is a newer area of research that is rapidly growing. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery. Recent literature suggests that adjuvant AOMs may address weight regain and inadequate weight loss following bariatric surgery. Research on neoadjuvant AOM used to optimize weight loss before bariatric surgery is more limited. A literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-four studies were included after screening and exclusion of irrelevant records. Included studies were as follows: seven prospective studies on adjuvant AOM use, 23 retrospective studies on adjuvant AOM use, one prospective study on adjuvant and neoadjuvant AOM use, one retrospective study on adjuvant or neoadjuvant AOM use, one prospective study on neoadjuvant AOM use, and one case series on neoadjuvant AOM use. In the following scoping review, each of these studies is discussed with the goal of presenting a complete synthesis of the current body of literature on AOM use in combination with bariatric surgery.

Temporary Mechanical Circulatory Support During Bariatric Surgery: A Novel Bridge to Durable Left Ventricular Assist Device and Cardiac Transplantation

Advanced heart failure (HF) with comorbid severe obesity presents a unique surgical dilemma: bariatric surgery may help patients meet cardiac transplantation body mass index (BMI) criteria, but poor cardiac function puts them at increased intraoperative risk. Per International Society for Heart and Lung Transplantation (ISHLT) guidelines BMI > 35 is a contraindication for orthotopic heart transplantation. Temporary mechanical circulatory support (MCS) with Impella 5.5 during bariatric surgery, as presented in this report, may help solve this dilemma for some patients. We present three patients with severe obesity and advanced heart failure (HF) who underwent successful bariatric surgery while supported by Impella 5.5 (Abiomed, Inc., Danvers, MA).

How Does Oversewing/Suturing (OS/S) Compare to Other Staple Line Reinforcement Methods? A Systematic Review and Meta-Analysis

Various staple line reinforcement (SLR) techniques in sleeve gastrectomy, including oversewing/suturing (OS/S), gluing, and buttressing, have emerged to mitigate postoperative complications such as bleeding and leaks. A meta-analysis of randomized controlled trials has demonstrated OS/S as an efficacious strategy for preventing postoperative complications, encompassing leaks, bleeding, and reoperations. Given that OS/S is the sole SLR technique not incurring additional costs during surgery, our study aimed to compare postoperative outcomes associated with OS/S versus alternative SLR methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed the literature and conducted fifteen pairwise meta-analyses of comparative studies, each evaluating an outcome between OS/S and another SLR technique. Thirteen of these analyses showed no statistically significant differences, whereas two revealed notable distinctions.

The Effect of Bariatric Surgery on Patients with Heart Failure: a Systematic Review and Meta-analysis

The current study aims to evaluate the effect of bariatric metabolic surgery (BMS) on the New York Heart Association (NYHA) class and left ventricular ejection fraction (LVEF) in patients with diagnosed heart failure (HF). Fourteen related articles with 217 patients were included in the final analysis. LVEF significantly improved after BMS in patients with HF with a mean difference of 7.78% (CI 95%: 3.72, 11.84, I2 = 83.75, p-value < 0.001). Also, the NYHA class significantly decreased after BMS with a mean difference of - 0.40 (CI 95%: - 0.62, - 0.19, I2: 47.03, p-value < 0.001). A total of 27 patients with obesity and HF were listed for cardiac transplantation after BMS. Of those, 20 patients successfully underwent heart transplantation after BMS.