Surgery for Obesity and Related Diseases ] (2014) 00–00

Original article

Bariatric surgery: a safe and effective conduit to cardiac transplantation Krzysztof J. Wikiel, M.D.*, Carol A. McCloskey, M.D., Ramesh C. Ramanathan, M.D. University of Pittsburgh Medical Center, Pittsburgh, PA Received August 6, 2013; accepted November 4, 2013

Abstract

Background: Obesity and obesity-related co-morbidities, including advanced heart failure, are epidemic. Some of these patients will progress to require cardiac allografts as the only means of long-term survival. Unfortunately, without adequate weight loss, they may never be deemed acceptable transplant candidates. Often surgical weight loss may be the only effective and durable option for these complex patients. The objective of this study was to assess whether bariatric surgery is feasible and safe in patients with severe heart failure, which in turn, after adequate weight loss, would allow these patients to be listed for a heart transplant. Methods: Four patients who underwent bariatric procedures, such as laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG), for the purpose of attaining adequate weight loss with the goal to improve their eligibility for orthotopic heart transplants are presented. Results: All patients did well around the time of surgery, and 3 of the 4 progressed to receiving a heart transplant. The fourth patient will be listed pending attaining adequate weight loss. Conclusion: Bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure. With the appropriate infrastructure, bariatric surgery is a feasible and effective weight loss method in this population. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Keywords:

Morbid obesity; Bariatric surgery; Laparoscopic Roux-en-Y gastric bypass; Laparoscopic sleeve gastrectomy; Heart failure; Heart transplantation

Obesity is an ongoing epidemic throughout the United States and the world. Current studies show that 68% of the population is classified as either obese or overweight, and all U.S. states have an obese population Z20% [1]. Looking further at the problem, the incidence of morbid obesity (body mass index [BMI] Z40 kg/m2) in young adults has now reached 6% [2]. As the rate of obesity increases in the general population, so does the incidence of obesity-related diseases such as hypertension, diabetes, and hyperlipidemia, which in turn can lead to heart disease and in some cases even to heart failure [3]. There are several physiologic mechanisms that may be responsible for the increased risk of heart failure in *

Correspondence: Krzysztof J. Wikiel, M.D., Magee-Womens Hospital of UPMC, Minimally Invasive Bariatric and General Surgery, 3380 Boulevard of the Allies, Pittsburgh, PA 15213. E-mail: [email protected]

the obese population, and a relationship between these 2 disease processes has been shown [4]. As this epidemic expands, physicians will continue to see an increasing number of obese patients with severe heart failure, some of whom will eventually progress to a point at which an orthotopic heart transplant may be the only means of longterm survival. Unfortunately transplant surgery in the obese population is associated with multiple risks. Over the past 50 years, heart transplantation has become the treatment choice for end-stage heart disease. Survival has greatly improved, with some current reports stating a 5-year survival of 480% [5]. As of now, this treatment option is generally reserved for patients with considerable cardiac dysfunction and a left ventricular ejection fraction (LVEF) under 20%. In general, the indications for a heart transplant include patients who have deteriorating cardiac function and a prognosis of o1 year to live. Unfortunately, despite the advances in medical technology, the main limiting factor for

1550-7289/13/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.11.002

K. J. Wikiel et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00

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heart transplantations is the availability of donor organs. Thus, patient selection remains stringent [6]. It is also important to state that, traditionally, obesity has been a relative contraindication to cardiac transplantation [4,7,8]. Obesity and its associated co-morbidities can make heart transplantation much more complex. In fact, obesity is considered a risk factor for mortality after heart transplantation [9]. Unfortunately, attaining successful weight loss in patients with significant heart failure using medical therapy alone can prove to be extremely difficult. Often the only option of durable weight loss in this population is through surgical means [7]. The present study reports 4 patients who underwent successful minimally invasive bariatric procedures as a bridge to cardiac transplantation. Materials and methods Since 2003, 4 morbidly obese patients have undergone bariatric surgery at our institution with the primary goal of becoming a better candidate for heart transplantation. These patients underwent laparoscopic sleeve gastrectomy (SG, n ¼ 2) or laparoscopic Roux-en-Y gastric bypass (LRYGB, n ¼ 2). All of these patients presented with a history of congestive heart failure secondary to nonischemic cardiomyopathy; heart failure was rated according to New York Heart Association criteria, and the degree ranged from group II–IV, with LVEF based on preoperative echocardiograms of 10%–25%. Two of the patients had a left ventricular assist device (LVAD) implanted before bariatric surgery. The average age of the patients was 40 (29–56) years old, and the average BMI was 48 (43–52) kg/m2. These data are summarized in Table 1. In addition to cardiomyopathy and advanced heart failure, the patients presented with co-morbidities commonly seen in the bariatric population (Table 2). Additionally, all patients were on prophylactic anticoagulants (warfarin, n ¼ 4), either because of preoperative arrhythmias (n ¼ 2) or implanted cardiac devices (n ¼ 2). Oral anticoagulation was stopped on preoperative day number 5, and therapeutic dose enoxaparin was started and continued until 24 hours before the surgery. On postoperative day 1, the patients were started on heparin drip without bolus. This was gradually advanced therapeutic level (aPTT of 55–75), Table 1 Preoperative information and overall clinical condition of the patients Patient number

Age

NYHA

EF, %

LVAD

BMI (kg/m2)

Weight in kg

1 2 3 4

29 40 43 56

II II III/IV III

15–20 20–25 10–15 20–25

Yes Yes No No

52 51 43 45

156 173 127 147

BMI ¼ body mass index; EF ¼ ejection fraction; LVAD ¼ left ventricular assist device; NYHA ¼ New York Heart Association Classification.

Table 2 Reported co-morbidities in our patients Co-morbidity

Number of patients

Hypertension Gastroesophageal reflux Hyperlipidemia Sleep apnea Renal insufficiency Pulmonary hypertension Diabetes mellitus (type 2) Cholelithiasis Asthma

3 3 3 3 2 2 2 1 1

under careful observation, to ensure patients are tolerating the treatment well. Later, when tolerating oral intake, the patients were converted back to warfarin with goal INR 2– 3. Achieving adequate anticoagulation is especially important in LVADs patients to prevent adverse thrombotic events dealing with the device. Results All patients underwent a successful uncomplicated bariatric procedure. Each patient was postoperatively admitted to the intensive care unit for postoperative and cardiac care. Average stay in the hospital after surgery was 6.5 (5–9) days. All patients underwent an upper gastrointestinal imaging study, and no leaks or obstructions were noted. Diets were started per protocol, advanced and tolerated. Three of the patients had postoperative complications (Table 3). One patient had reported gastrointestinal bleeding, likely as a result of anastomotic bleeding and restarting of anticoagulation. This was managed conservatively, and he did not require transfusions of blood products or additional surgery. The anticoagulation was eventually restarted without further incidents. Two additional patients, both with preoperative history of arrhythmia, had episodes of rapid ventricular response atrial fibrillation successfully treated pharmacologically. One of those patients additionally had symptoms of fluid overload that required treatment with additional intravascular diuretics. None of the patients required readmission within the first 30 days of surgery. There were no reported wound complications. Table 3 Procedures, perioperative information, and complications Procedure 1 2 3 4

SG LRYGB SG LRYGB

Surgery time 3:22* 2:02 N/A N/A

Hospital stay (days)

Complications (30 day)

9 7 5 5

Arrhythmia, fluid overload Gastrointestinal bleeding Rapid rate atrial fibrillation None

LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; SG ¼ laparoscopic sleeve gastrectomy. * Surgery time was longer because it was performed with concomitant cholecystectomy with evidence of chronic cholecystitis.

Bariatric Surgery: A Conduit to Cardiac Transplant / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 4 Time to cardiac transplantation and weight loss at the time of the cardiac transplantation Patient number

Heart transplantation

BMI (kg/m2)

Weight (kg)

EWL

Months after bariatric surgery

1 2 3 4

Yes No Yes Yes

39 N/A 36 29

126 N/A 109 94

38% N/A 32% 77%

17 N/A 8 15

BMI ¼ body mass index; EWL ¼ excess weight loss.

In the time period before cardiac transplantation, the patients did well and did not have any major complications or readmissions stemming directly from bariatric surgery (i.e., nausea, emesis, dysphagia, abdominal pain, etc.). Three of the 4 patients, who attained what was deemed sufficient weight loss, were placed on transplant list and eventually received a cardiac graft. The average time from bariatric surgery to cardiac transplantation was 13 (8–15) months. At the time of transplantation, patients' mean percentage excess weight loss was 32%–77%, and average BMI was 35 (29–39) kg/m2 (Table 4). At present follow-up, 2 of the 3 cardiac recipients are deceased (Table 5). One patient died 9 months after cardiac transplantation of complications from a cerebrovascular accident. The other patient survived 48 years after transplantation. He died from complications related to chronic renal failure. The third patient is doing well, and it has been 42 years since his cardiac transplantation. This patient regained approximately 6 kg (13.2 lbs) after the heart transplantation, but now his weight has stabilized and BMI has remained just under 40 kg/m2. The other 2 patients maintained or decreased their weights after the cardiac transplantation. The fourth patient, who is currently waiting for a cardiac graft is also doing well. At this time, about 16 months from the LRYGB, he has achieved approximately 40% excess weight loss. Discussion Obesity is reaching epidemic proportions worldwide [1]. There is also a clear association between obesity and Table 5 Long-term outcomes Patient Last reported number weight (kg)

Last reported BMI (kg/m2)

Outcome 28 months after transplant, doing well Transplant pending weight loss (goal BMI 36) Died 101 months after transplant Died 9 months after transplant

1

133

40

2

134

39

3

99.5

33

4

93

29

BMI ¼ body mass index.

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cardiovascular disease as a result of common comorbidities in the obese. There are also data to suggest that excess weight is likely an independent risk factor for cardiomyopathy and subsequent heart failure because of its effects on cardiac physiology and structure [4]. It has been well established that morbid obesity is difficult to treat nonsurgically. This is definitely exacerbated by concomitant heart failure, because these patients often have multiple co-morbidities such as hypertension, diabetes, sleep apnea, pulmonary hypertension, or arrhythmias. This is compounded by limited exercise tolerance in this group, resulting in high likelihood of the patients increasing their weight, worsening heart failure, and further limiting functional status [7]. Overall morbid obesity and heart failure have a negative synergistic effect on the patient’s functional capacity, and in turn, this may mean poor long-term survival. Because of the above, achieving adequate longterm weight loss in the obese patients by nonsurgical means may be nearly impossible. Bariatric surgery, especially with the decreased risks associated with minimally invasive techniques, may be the only effective and durable treatment option for these patients [7]. With adequate weight loss after bariatric surgery, some of these patients may become appropriate transplant recipients. Morbid obesity has classically been considered a relative contraindication for cardiac transplantation [8]. It has also been reported that patients with BMI 435 kg/m2 are 46% less likely to receive a heart transplant than normal weight patients [10]. Patients with higher BMI are often not even placed on the transplant lists. There are many reasons for this. Firstly, any complex surgery in the bariatric population can be risky secondary to common co-morbidities seen in morbidly obese individuals such as diabetes, hepatosteatosis, obesity hypoventilation syndrome with hypoxia, or pulmonary hypertension [11]. Kilic et al. report that obesity, hypertension, and diabetes mellitus are associated with significant increase in postoperative mortality after heart transplantation. If a prospective patient has all 3 conditions, there is 63% increase in mortality [12]. Heart transplantation is further complicated in the obese, because weight gain partly due to the corticosteroid regimen is noted, further compounding preoperative obesity [13]. It has already been reported that bariatric surgery is both feasible and effective for obese patients with severe cardiomyopathy; the authors’ team previously reported 14 patients with severe heart failure who underwent successful bariatric surgery [4]. Furthermore, it is important to mention that there have been several reports of actual improvement of cardiac function in these patients after surgically-induced weight loss [4,7,14]. Ristow et al. reported 2 patients with severe heart failure who underwent SG, and 5 months after surgery, both patients attained adequate weight loss. Additionally, these patients had significant improvement of their cardiac parameters [14]. In the study previously reported

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K. J. Wikiel et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00

from the authors’ center, 8 of 14 patients had improvement LVEF [4]. Thus, improvements in cardiac function after bariatric surgery could delay or alleviate the need for transplantation in some patients. In the setting of patients who progress to needing a cardiac transplant, adequate weight loss after bariatric surgery will allow them to be considered as optimal cardiac graft recipients. Availability of organs still remains the most important limiting factor in cardiac transplantation [6]; therefore, it is extremely important to match the organs to recipients in such a way to allow for best chance of long-term survival. Among many important parameters reviewed while matching a donor and a recipient, size needs to be strongly considered. There is not much published data concerning morbidly obese cardiac recipients, but size mismatch may play an important role when the recipient is morbidly obese. For example, there was a report of a patient developing a coronary artery fistula that drained into the pulmonary artery and subsequent deterioration of cardiac function 5 years after the transplantation. This was attributed to cardiac graft and recipient size mismatch, because in that case a smaller heart was placed into a larger recipient [15]. Overall weight ratios between the donor and recipient may not be a good predictor of outcomes, but it has been reported that in certain groups, such as patients with elevated pulmonary resistance, transplanting an undersized heart may be met with poor outcomes [16]. Although many advances have been achieved in transplant medicine, still as of now patients who receive a solid organ allograft will require aggressive life-long immunosuppressive therapy to prevent organ rejection. This is a very important consideration in the obese population. Patients requiring corticosteroid therapy will be likely to have increased blood pressures and adversely affected glucose and lipid metabolisms, and at higher doses, steroids can increase appetite and further promote weight gain. Calcineurin inhibitors (CNI), which are a mainstay of immunosuppressive therapy, also have important side effects to consider. Cyclosporine has been known to worsen hypertension and cause hyperlipidemia, and tacrolimus has been associated with negative effect on glucose metabolism. Sirolimus, while not a CNI has similar effects and has been associated with new onset diabetes and onset of intractable hyperlipidemia [17,18]. All of the complications above will likely play an important role in survival of the morbidly obese patient, because they may worsen common comorbidities found in this population. Additionally, dosing adjustments may need to be considered in the obese patients, but unfortunately, there is not much data concerning this in current literature. Most transplant medications, such as CNIs, have complex pharmacodynamics and require monitoring to prevent devastating side effects such as nephrotoxicity [18,19]. It is unclear how morbid obesity affects blood levels of these medications and if and how the dosing should be adjusted.

There is also a paucity of data regarding the weight loss goal at which point it is safer to perform cardiac transplantation. It appears that most centers prefer to transplant patients with BMI o35 kg/m2 [10]. This is further supported by the fact that overweight patients (BMI 25–30 kg/ m2) and those with mild obesity (o35 kg/m2) tend to do better from a cardiac standpoint, and this actually may be advantageous in terms of long-term survival. This is illustrated by multiple reports of the “obesity paradox” [20,21]. Additionally, it has been reported that being overweight (BMI 25–30 kg/m2) can be advantageous for survival during the critically ill period before cardiac transplantation. Komoda et al. reported that patients classified as overweight had a higher 1-year survival than both the normal weight and obese individuals (74% versus 62% and 50.6%, respectively) [9]. With that said, it is very important to emphasize that the obese patients had considerably lower survival than either of the groups and are encouraged to reduce their weight. While discussing bariatric surgery in the morbidly obese with heart failure, many things have to be considered, including selection of the appropriate procedure and which would be the safest option in these complex patients. With the advancement of surgical techniques, over 90% of bariatric surgeries, such as adjustable gastric band (LAGB), SG, and LRYGB, are performed laparoscopically. This in turn has likely resulted in overall improvement of outcomes [22]. Nevertheless, despite overall improvement in mortality and morbidity in bariatric surgery, operating on patients with heart failure carries significant risks, and it is extremely important to consider risks and benefits of all the options. It is also important to mention here that, in the present study, the port placement in the patient with history of LVAD had to be altered only minimally. As the device was placed over the left lower chest and left upper abdomen, the left upper quadrant port had to be moved inferiorly. This did not have a significant effect on the technical aspects of the case. There are 2 reports of placing LAGB in patients with heart failure [23,24]. Samaras et al. describe 2 patients who received adjustable gastric bands. The first patient, initially with BMI of 41 kg/m2, had lost 34 kg and attained a BMI of 31 kg/m2 at 11 months after placement of the band. Although, his diabetes and hyperlipidemia improved, his cardiac function did not. He underwent a successful cardiac transplantation at 13 months after the bariatric procedure. The second patient also had significant weight loss. Her cardiac function improved, and she did not require a cardiac transplant [23]. Gill et al. reported 2 patients who underwent a concomitant ventricular assist device and LAGB. After sustaining significant weight loss, both patients have BMI o35 kg/m2 and have now been listed for cardiac transplant. Placement of the band added only approximately 30 minutes to the procedures and did not have an effect on the initial outcomes. Both patients showed some improvement in cardiac function [24].

Bariatric Surgery: A Conduit to Cardiac Transplant / Surgery for Obesity and Related Diseases ] (2014) 00–00

Although LAGB may be a good option because it is the least invasive of the available bariatric procedures, the benefit profiles must be considered as well. Studies have shown that bands can provide effective long-term weight loss, with nearly half of excess weight loss reported [25]. On the other hand, multiple reports show a clear advantage of LRYGB and SG over the LAGB. It has been suggested that LRYGB is most advantageous to the patient in terms of both weight loss and reduction of co-morbidities such as diabetes, hypertension, hyperlipidemia, and sleep apnea, all of which play a role in cardiovascular health [22,26]. Along the same lines, there have been reports that SG can resolve or significantly improve medical ailments, such as hypertension, diabetes, or sleep apnea, much more so than nonsurgical methods [27]. It is also important to mention, that in our experience weight loss after SG or LRYGB is more rapid, and this may allow placement of the patients on the transplant list more expeditiously. Additionally, when selecting an optimal bariatric operation for a potential cardiac allograft recipient, one needs to consider how the procedure will affect absorption of immunosuppressive medication. SG is a purely restrictive procedure and should not cause significant malabsorption of those vital medications. Finally, operative times for SG observed at the authors’ center are considerably shorter than times seen while performing LRYGB and, therefore, make it an attractive option in this patient population. Bariatric surgery patients with severe heart failure are quite complex from a medical standpoint and require complex care. Firstly, as in the present study, these patients often suffer from multiple other co-morbidities in addition to the heart failure and obesity. Many of these patients will receive chronic anticoagulation. For example, patients in the present study had either history of arrhythmias or required a LVAD. During the immediate perioperative period, the patients should be managed by an anesthesiology team with experience in management of high-risk cardiac patients to ensure adequate heart function throughout the procedure. Postoperatively, these patients will also require a multidisciplinary approach, intensive cardiac care, and access to a cardiologist and cardiac surgeons, as well as to bariatric specialists [4]. Thus routine operations on these patients can only be safely performed at tertiary centers with appropriate amenities. The authors acknowledge several limitations to this study. Unfortunately, the number of patients actually becoming transplant recipients is still small, and this does not allow for any meaningful statistical analysis. The reason for this is twofold. On one hand, there are only a few patients with obesity and severe heart failure who had undergone bariatric procedures. On the other hand, as stated by the multiple reports noted above, a good proportion of these patients will actually have sufficient improvement of cardiac function as a result of the weight loss, and a heart transplant may not become necessary [4,7,23,24]. Along the

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same lines, the small number of patients does not allow for a good evaluation of the risk profile. Patients in the present study mostly had only minor complications associated specifically with bariatric surgery, but even given the small study group, there were some complications directly associated with history of cardiac disease, such as arrhythmias and fluid overload. Additionally, one patient in the present study suffered a complication likely resulting from anticoagulation. Conclusion Although this is a high-risk population, bariatric procedures may be an important bridge to transplantation for morbidly obese patients with severe heart failure. With the appropriate infrastructure, bariatric surgery is feasible and effective in this population. Additionally, many of these patients may actually improve to the point at which they may not need cardiac transplantation. Selection of the appropriate procedure type should be done on a case-bycase basis, but over time, SG may prove to be a better choice, because the weight loss and metabolic benefits are only slightly inferior to LRYGB and are accomplished with a less complex procedure. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Matthews CM. Exploring the obesity epidemic. Proc (Bayl Univ Med Cent) 2012;25:276–7. [2] Koebnick C, Smith N, Huang K, Martinez MP, Clancy HA, Kushi LH. The prevalence of obesity and obesity-related health conditions in a large, multiethnic cohort of young adults in California. Ann Epidemiol 2012;22:609–16. [3] Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous physical activity and the risk of heart failure among men. Circulation 2009;119:44–52. [4] McCloskey CA, Ramani GV, Mathier MA, et al. Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy. Surg Obes Relat Dis 2007;3:503–7. [5] Guethoff S, Meiser BM, Groetzner J, et al. Ten-year results of a randomized trial comparing tacrolimus versus cyclosporine a in combination with mycophenolate mofetil after heart transplantation. Transplantation 2013;95:629–34. [6] Copeland JG, Emery RW, Levinson MM, et al. Selection of patients for cardiac transplantation. Circulation 1987;75:2–9. [7] Ramani GV, McCloskey C, Ramanathan RC, Mathier MA. Safety and efficacy of bariatric surgery in morbidly obese patients with severe systolic heart failure. Clin Cardiol 2008;31:516–20. [8] Cimato TR, Jessup M. Recipient selection in cardiac transplantation: contraindications and risk factors for mortality. J Heart Lung Transplant 2002;21:1161–73. [9] Komoda T, Drews T, Hetzer R, Lehmkuhl HB. Overweight is advantageous for heart-transplant candidates to survive the period of critically ill status. ASAIO J 2012;58:390–5.

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[10] Weiss ES, Allen JG, Russell SD, Shah AS, Conte JV. Impact of recipient body mass index on organ allocation and mortality in orthotopic heart transplantation. J Heart Lung Transplant 2009;28: 1150–7. [11] Bray GA. Complications of obesity. Ann Intern Med 1985;103: 1052–62. [12] Kilic A, Conte JV, Shah AS, Yuh DD. Orthotopic heart transplantation in patients with metabolic risk factors. Ann Thorac Surg 2012;93:718–24. [13] Costanzo MR, Augustine S, Bourge R, et al. Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation 1995;92:3593–612. [14] Ristow B, Rabkin J, Haeusslein E. Improvement in dilated cardiomyopathy after bariatric surgery. J Card Fail 2008;14:198–202. [15] Matsubara TJ, Iwata H, Shiga T, et al. Progressive coronary arterypulmonary artery fistula after size-mismatch cardiac transplantation. ASAIO J 2011;57:346–7. [16] Patel ND, Weiss ES, Nwakanma LU, et al. Impact of donor-torecipient weight ratio on survival after heart transplantation: analysis of the United Network for Organ Sharing Database. Circulation 2008;118(Suppl 14):S83–8. [17] Hricik DE. Metabolic syndrome in kidney transplantation: management of risk factors. Clin J Am Soc Nephrol 2011;6:1781–5. [18] Keogh A. Calcineurin inhibitors in heart transplantation. J Heart Lung Transplant 2004;23(Suppl 5):S207–13.

[19] Eisen H, Ross H. Optimizing the immunosuppressive regimen in heart transplantation. J Heart Lung Transplant 2004;23(Suppl 5):S207–13. [20] De Pergola G, Nardecchia A, Giagulli VA, et al. Obesity and heart failure. Endocr Metab Immune Disord Drug Targets 2013;13:51–7. [21] Chrysant SG, Chrysant GS. New insights into the true nature of the obesity paradox and the lower cardiovascular risk. J Am Soc Hypertens 2013;7:85–94. [22] Jackson TD, Hutter MM. Morbidity and effectiveness of laparoscopic sleeve gastrectomy, adjustable gastric band, and gastric bypass for morbid obesity. Adv Surg 2012;46:255–68. [23] Samaras K, Connolly SM, Lord RV, Macdonald P, Hayward CS. Take heart: bariatric surgery in obese patients with severe heart failure. Two case reports. Heart Lung Circ 2012;21:847–9. [24] Gill RS, Karmali S, Nagandran J, Frazier HO, Sherman V. Combined Ventricular Assist Device Placement With Adjustable Gastric Band (VAD-BAND): a promising new technique for morbidly obese patients awaiting potential cardiac transplantation. J Clin Med Res 2012;4:127–9. [25] O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257:87–94. [26] Weber M, Müller MK, Bucher T, et al. Laparoscopic gastric bypass is superior to laparoscopic gastric banding for treatment of morbid obesity. Ann Surg 2004;240:975–82, discussion 982–3. [27] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567–76.

Bariatric surgery: a safe and effective conduit to cardiac transplantation.

Obesity and obesity-related co-morbidities, including advanced heart failure, are epidemic. Some of these patients will progress to require cardiac al...
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