The Impact of Obesity on Patients Bridged to Transplantation With Continuous-Flow Left Ventricular Assist Devices

Abstract

Objectives This study sought to determine if obese patients had worse post-LVAD implantation outcomes and if the implantation of an LVAD allowed for weight loss. Background Obesity is a risk factor for cardiovascular disease including heart failure. Obese heart failure patients have better outcomes than those with normal weight; however obese patients have worse outcomes following heart transplantation. Methods Patients were identified in the UNOS database that underwent LVAD implantation as bridge to transplantation from May 2004 and April 2014, with follow-up through June 2014. Patients were grouped according to BMI based on the WHO classification Results Among 3,856 patients the risk of death or delisting was not significantly different between BMI groups (p=0.347). There was no increased risk of death (p=0.234) or delisting (p=0.918). The risk of complication requiring UNOS status upgrade was increased for those with Class II obesity or greater (HR 1.48, 95% CI 1.14–1.93, p=0.004), driven by increased infection and thromboembolism. Obese patients had worse post-transplant outcomes. Weight loss substantial enough to decrease BMI group was achieved by a small proportion of patients listed with Class I obesity or greater (9.6–15.5%). Conclusions Patients with obesity had similar freedom from death or delisting while on LVAD support. However, Class II obese or greater patients had an increased risk of complications requiring UNOS status upgrade compared with those with normal BMI during LVAD support and decreased post-transplant survival. Weight loss on device therapy was possible, but uncommon. Careful consideration is needed when a bridge to weight loss strategy is proposed.

Durable left ventricular assist device implantation in extremely obese heart failure patients

“…Our work confirms the results of several recent studies, which failed to detect a significant difference in short‐term and intermediate postoperative survival between obese and nonobese LVAD recipients . However, higher rates of hospital readmissions and complications such as AKI , infection , thromboembolism , and PT are often present in the obese cohort. We observed higher rates of stage 2/3 AKI and PT in the extremely obese cohort, which is in agreement with prior studies .…”

Impact of pretransplant recipient body mass index on post heart transplant mortality: A systematic review and meta‐analysis

“…transplantation. Of patients with a left ventricular assist device, only 33% of underweight patients gained weight to a higher BMI category 29. This relative risk estimate is comparable to that of other relative contraindications to transplant including: Age > 70 (HR 1.289, 95% CI 1.039-1.6),27 and renal dysfunction with eGFR < 50 mL/min (HR 1.55, 95% CI 1.33-1.81) 28.…”

“…Further, in adult or elderly underweight patients (age > 39 or >65, and BMI < 18.5 kg/m 2 ), we observed 24% and 70% increase in risk of mortality, respectively. In the obese and severely obese, only 4% and 19% lost weight to a lower BMI category, respectively 29. Given that the relative risk of underweight BMI in older patients is similar to that of other relative contraindications, such patients should be recommended to gain weight prior to listing for transplantation.…”

“…In patients with advanced heart failure, weight change to improve health status may be challenging due to the anorexia and nausea that frequently accompany advanced symptoms. Of patients with a left ventricular assist device, only 33% of underweight patients gained weight to a higher BMI category 29. In the obese and severely obese, only 4% and 19% lost weight to a lower BMI category, respectively 29.…”

“…Of patients with a left ventricular assist device, only 33% of underweight patients gained weight to a higher BMI category 29. In the obese and severely obese, only 4% and 19% lost weight to a lower BMI category, respectively 29. Strategies to correct underweight or obesity should be encouraged earlier in the disease course.…”