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Narvaez et al. Mini-invasive Surg 2020;4:31 I http://dx.doi.org/10.20517/2574-1225.2020.22 Page 3 of 4

EWL), 3 months with 21% EWL, and 6 months with 27% EWL. At 12 months, the patient had 39% EWL,
2
reached a BMI of 36 kg/m , and was 11 pounds from the goal weight. Exercise tolerance improved, oxygen
was no longer required, and NYHA Class II-III symptoms were noted. In addition, hospitalizations for HF
decreased to two admissions over one year and EF was stable at 25%. By 15 months, the patient presented
in cardiogenic shock and ultimately required LVAD placement for cardiac stabilization.

DISCUSSION
Obesity is a risk factor for the development of cardiovascular disease and HF. Heart transplant is
the primary treatment for end-stage HF; however, morbid obesity is a relative contraindication to
2
[8]
transplantation . A BMI ≥ 35 kg/m is associated with early complications and decreased long-term
[2]
survival after heart transplant, compared to class I obesity . Weight loss improves cardiovascular
function through increased left ventricular diastolic and systolic function, reduction of myocardial
[4]
oxygen consumption, and reversal of impaired aortic distensibility . The Swedish Obese Subjects study
demonstrated sustained weight loss and decreased cardiovascular events, including death, after bariatric
[9]
surgery . Thus, bariatric surgery is an effective intervention for morbidly obese patients who require
weight reduction to become a candidate for heart transplantation.

Bariatric surgery in patients with severe cardiomyopathy, including LVAD, is an opportunity for rapid
weight loss as a “bridge” to transplantation. Studies of small cohorts show patients with LVAD who
underwent bariatric surgery had improvement in median left ventricular ejection fraction and reduction
[6]
in NYHA classification [6,10] . In particular, Punchai et al. reported on three patients with LVAD who went
on to receive a heart transplant after LSG. Acceptable rates of complications included five perioperative
morbidities and two deaths from LVAD complications. LVAD complications occur at a rate of 8%-29%
[11]
and include: bleeding, infection, neurologic event, and anticoagulation issues . In addition, mechanical
circulatory support devices are associated with heightened healthcare costs. The total cost for LVAD as a
[12]
bridge to transplantation ranges from $316,078 to $1,025,500 . Further cost of management includes the
[12]
median cost of a single readmission at $7,546; with up to 81.8% of LVAD patients requiring readmission .
Options for our patient were to perform weight loss surgery: (1) after further deterioration that required
LVAD implementation or (2) with the option of temporary mechanical support with IABP. The early
intervention of LSG improved cardiac function and symptoms for more than one year although, an episode
of cardiogenic shock ultimately required LVAD placement. While the progression to LVAD is an acceptable
risk, this case describes the multidisciplinary team approach critical to successful LSG in a patient with
complex heart disease.

To the best of our knowledge, this is the first report of the temporary use of an IABP to achieve
uncomplicated bariatric surgery in a high-risk patient with advanced cardiac disease. The IABP has been
[13]
utilized to establish hemodynamic stability in patients awaiting cardiac surgery with decompensated HF ,
but rarely reported in non-cardiac surgery. Successful placement of an IABP in patients with congestive HF
who underwent non-cardiac procedures (nephrectomy, colectomy with splenectomy, and an exploratory
[14]
laparotomy) potentially reduced morbidity and mortality . Similarly, the temporary mechanical
circulatory assistance of the IABP resulted in a successful LSG, without morbidity or mortality. As a result,
the multidisciplinary team approach resulted in safe bariatric surgery, in a hospital with the infrastructure
to manage advanced HF.

In conclusion, the temporary application of an IABP provides cardiovascular support to achieve a safe LSG.
A multidisciplinary team approach is recommended for perioperative management of advanced HF.