Sleeve Gastrectomy and Left Ventricular Assist Device for Heart Transplant

Background and Objectives: Heart failure (HF) is a severe obesity-related comorbidity. Many patients with end-stage HF eventually require cardiac transplantation for long-term survival. These patients may be precluded from enrollment in heart transplant programs secondary to morbid obesity. We propose a pathway involving sleeve gastrectomy (SG) for patients with morbid obesity and HF to afford cardiac transplantation eligibility. Methods: Three patients with HF and morbid obesity underwent implantation of a left ventricular assist device (LVAD) and SG at an academic tertiary care institution in Washington, DC. This retrospective review from April 2012 through January 2017 examines the perioperative course of these 3 patients with regard to bariatric and cardiac indices, including ejection fraction (EF), HF classification, comorbid diseases, and percentages of total weight loss (% TWL) and excess weight loss (% EWL). Results: All three patients underwent LVAD placement as a bridge to transplant but were excluded from cardiac transplantation secondary to body mass index (BMI) and were referred for bariatric surgery. All have demonstrated considerable weight loss, with average decrease in BMI of 19 points, 39% TWL, and 81% EWL at a mean of 44 months after SG. Two patients have gone on to receive heart transplants, with near normalization of their EF. Conclusion: LVAD and SG constitute a feasible pathway to cardiac transplantation in morbidly obese patients with end-stage HF. LVAD permits temporary cardiac support, whereas SG assists in efficacious weight loss. We explore SG as a durable weight loss option in patients with HF, with LVAD to improve eligibility for orthotopic cardiac transplantation.