Patients and Methods

Our retrospective, single-center cohort analysis included 22 patients with a BMI of 35 or higher and end-stage HF (Table I). From January 2013 through July 2018, the patients underwent LVAD placement and LSG during the same hospitalization as BTT therapy. From chart reviews, we collected baseline data on age, sex, height, date of LVAD placement, date of LSG, and body weight before LSG. Body mass index was calculated as weight in kilograms divided by height in meters squared. Follow-up data were collected on body weight after LSG, as well as the date of HT listing or LVAD explantation, when applicable. Listing status and deaths were monitored for 18 months, and in one case, through October 2020. Records were given study numbers for privacy, and our local institutional review board waived the need for written informed consent.

TABLE I. Body Mass Index and Percentage of Weight Loss in the 22 Patients Over 18 Months

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Dietary Protocol

After LSG and while still hospitalized, the patients were introduced to the 4-stage dietary protocol developed at our institution (Table II). The weight-loss diet progresses from clear liquids to solid food and ultimately ends with a low-fat, low-carbohydrate plan. The multidisciplinary HF team encouraged patients to drink 48 to 64 ounces of water daily, to avoid using straws, and to limit alcohol and caffeine intake, as well as to eat small, frequent meals at a slow pace. After discharge from the hospital, the patients had follow-up appointments in our outpatient clinic. Our HF dietitians continued the diet education process, monitored compliance with the protocol, and provided ongoing weight-loss counseling. Depending on specific requests from the patients' physicians, the dietitians continued to monitor weight loss and provide medical nutrition therapy as needed.

TABLE II. Dietary Protocol After Longitudinal Sleeve Gastrectomy

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Results

Before LSG, 5 patients (22.7%) were in obesity class 2 (BMI 35 to <40), and 17 (77.3%) were in class 3 (BMI ≥40). Two of the class 3 patients had a BMI of greater than 50.

Fourteen patients (63.6%) achieved a BMI of less than 35 at 12 months, as did 16 patients (72.7%) at 18 months (Fig. 1). Of note, both patients with baseline BMIs greater than 50 reduced their BMIs to below 35.

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Two patients experienced myocardial recovery, and their devices were explanted. One, whose LVAD was explanted at 16 months, had lost 58.4% of body weight (BMI, 34.1); the other, explanted at 25 months, had lost 42.3% of body weight (BMI, 29.7).

Weight loss was not the sole factor affecting transplant eligibility in many cases. Each patient's clinical and social status was reviewed to determine access to postoperative care and support, as well as other medical conditions that could affect their clinical outcome. Ultimately, 11 patients (50%) were either listed for HT (n=10) or underwent LVAD removal (n=1) within 18 months (Fig. 2).

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All patients were alive at 18 months. Two patients died later. One, waitlisted at 12 months, underwent HT at 17 months and died 7 months later (24 mo after LVAD + LSG). His posttransplant course was complicated by primary graft dysfunction that necessitated venoarterial extracorporeal membrane oxygenation. Subsequent sepsis led to multiorgan failure, and the family decided to withdraw care. The other patient never achieved a BMI of less than 35 and died 40 months after LSG. Toxic metabolic encephalopathy of unknown cause was complicated by sepsis and retroperitoneal bleeding. The poor prognosis led the family to withdraw care.

As of October 2020, 10 patients (45.5%) had undergone HT, 5 (22.3%) were listed for HT, 2 (9%) had undergone LVAD explantation, and 5 still had a BMI ≥35 (Fig. 3). Seventeen of the 22 patients (77.3%) either were listed for HT or underwent successful LVAD removal. Their median time from LSG to listing or explantation was 362 days (IQR, 172–831 d). In the 10 transplanted patients, the median time from LSG to HT was 352 days (IQR, 225–496 d).

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Discussion

Our results show that LVAD support, LSG, and a dietary protocol with ongoing encouragement can enable patients to reduce their BMI. Most in our cohort achieved a BMI of less than 35 at 12 months, and more than half were either listed for HT or had recovered myocardial function at 18 months. Substantial weight loss improved their likelihood of HT and their chances of survival.

Of note, the therapy was not effective in all patients. Six of the 22 did not achieve a BMI of less than 35 in 18 months and, as of October 2020, 5 still struggled to lose weight.

Study Limitations. This retrospective review is limited in its application scope. The small sample size and single-center approach may have introduced bias. The data are accurate; however, conclusions must remain tentative until verification in a larger cohort. Regardless, the number of patients and duration of follow-up add to the relevant literature and can inform future studies. Prospective studies with larger sample sizes are needed.

Conclusion

Our data support LVAD placement and LSG for BTT in patients with morbid obesity and advanced HF. Adherence to a dietary protocol after LSG, with encouragement from physicians and dietitians, further aids long-term weight loss in this vulnerable patient population.