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Page 2 of 4 Narvaez et al. Mini-invasive Surg 2020;4:31 I http://dx.doi.org/10.20517/2574-1225.2020.22

CASE REPORT
A 43-year-old patient with non-ischemic cardiomyopathy, New York Heart Association (NYHA) Class
2
IIIb, and morbid obesity (BMI 45 kg/m ) was referred for weight loss prior to evaluation for heart
transplantation. Co-morbid conditions included obstructive sleep apnea, nonalcoholic steatohepatitis,
gastroesophageal reflux disease, hyperlipidemia, exertional hypotension, adrenal insufficiency, and 3L
continuous oxygen. The patient was diagnosed with HF three years prior with an ejection fraction (EF) of
15%-20%, which required an implantable cardioverter-defibrillator (ICD). Titration of antihypertensive
and diuretic medications was limited by syncope and hypotension. The patient was hospitalized over
thirteen times with episodes of HF exacerbation and arrhythmias. Ultimately, the ICD was converted to a
biventricular device, and EF improved to 25% with complete ventricular pacing. Our patient did not qualify
for left ventricular assist devices (LVAD), but still, weight loss surgery was recommended to improve
cardiac function and increase the potential for candidacy for heart transplant.

Preoperative care
Our multidisciplinary team consisted of advanced HF and transplant cardiology, cardiothoracic surgery,
cardiothoracic anesthesiology, and bariatric surgery. Diet modifications resulted in successful weight loss
of 9 pounds over ten months. Preoperative testing included an upper gastrointestinal series that revealed
normal esophageal motility, no hiatal hernia, and no gastroesophageal reflux. LSG was chosen over Roux-
en-Y gastric bypass for technical ease, shorter operative time, perioperative safety profile, and effective
[5-7]
weight loss in end-stage HF patients .

To address the perioperative risks of volume shifts and hemodynamic instability, preoperative placement
of an IABP was considered. The IABP was necessary to establish euvolemia prior to surgery and maintain
adequate cardiac output during laparoscopy. Over six months, the patient obtained clearances from
nutrition, psychology, endocrinology, pulmonology, and cardiology. The patient was pre-admitted to the
advanced HF team to address fluid shifts prior to surgery. An IABP was placed on hospital day 2 to prevent
hypotension with ongoing, supervised diuresis. A catheter was inserted through the right femoral artery
with a 7.5F sheath and advanced under fluoroscopic guidance into the descending thoracic aorta. The IABP
was turned on with continuous heparin infusion until 6 hours prior to surgery. Successful diuresis was
achieved with a negative fluid balance of 5 liters, without episodes of hypotension.

Surgical technique
Upon arrival to the operating room, the IABP was transferred from battery to an alternating current
power. After additional arterial and venous access was achieved, the case began with the placement of
four ports in the subcostal area with the option of low-pressure insufflation. The patient was gradually
positioned in reverse Trendelenburg as hemodynamic status was monitored. A liver retractor was placed
to expose the gastroesophageal junction. The greater curvature of the stomach was mobilized to the left
crus with cauterization of the short gastric blood vessels. Hemostasis was achieved and a 36F bougie was
passed into the gastric lumen. Sleeve gastrectomy was performed using staplers, at 4-5 mm and 3-4 mm
staple heights, with staple line reinforcement. Care was taken to ensure the incisura was not narrowed. An
esophagogastroduodenoscopy was performed with a negative leak test and symmetric stomach. Blood loss
was less than 50 mL and hemodynamic stability persisted throughout the case. The patient tolerated the
procedure without any complications and the continuous heparin infusion was restarted.

Post-operative outcomes
Diet was advanced on post-operative day (POD) 1 and the IABP was removed on POD 2. The patient was
discharged on POD 9 without complications, blood transfusions, or readmission. Follow-up visits with
the bariatric surgeon, dietitian, psychologist, or advanced HF cardiologist occurred at 3 weeks, 3 months,
6 months, and 1 year. Progressive weight loss occurred at 3 weeks with 8 percent excess weight loss (%