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Ventricular Remodeling Following Metabolic and Bariatric Surgery Decreases Need for Heart Transplantation: A
Armaun D Rouhi1, Rashikh A Choudhury2, Gerard D Hoeltzel3
1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Armaun.Rouhi@pennmedicine.upenn.edu.
Insights
Metabolic and bariatric surgery (MBS) improves survival for patients with obesity and congestive heart failure (CHF) awaiting heart transplantation (HT). MBS decreases transplant need and improves access to HT by lowering BMI.
Area of Science:
- Cardiology
- Bariatric Surgery
- Transplantation Medicine
Background:
- Obesity and congestive heart failure (CHF) pose challenges for heart transplantation (HT). Aggressive weight loss can cause ventricular remodeling, impacting systolic function.
- Metabolic and bariatric surgery (MBS) is increasingly considered for patients with obesity and CHF requiring HT.
Purpose of the Study:
- To evaluate the role and impact of MBS on heart transplantation outcomes for patients with obesity and CHF.
- To compare the effectiveness of different MBS procedures (Roux-en-Y gastric bypass and sleeve gastrectomy) versus diet and exercise for improving survival and transplant eligibility.
Main Methods:
- Markov decision analysis was used to simulate the life expectancy of 30,000 patients with obesity, CHF, and 30% ejection fraction (EF).
- Patients were modeled with a pre-intervention BMI of 45 kg/m², aiming for a BMI < 35 kg/m² for HT waitlisting.
- Life expectancy was estimated for diet and exercise (DE), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) interventions.
Main Results:
- Roux-en-Y gastric bypass (RYGB) was associated with lower rates of heart transplantation (HT) and quicker transplant acquisition when needed.
- RYGB patients gained an average of 2.2 years of survival compared to sleeve gastrectomy (SG) and 10.3 years compared to diet and exercise (DE).
- SG patients gained 6.2 mean years of life compared to DE.
Conclusions:
- Metabolic and bariatric surgery (MBS) significantly improves survival in patients with obesity, CHF, and reduced ejection fraction (EF) awaiting heart transplantation.
- MBS decreases the need for transplantation through improvements in EF and enhances access to HT by reducing average BMI.
- Both RYGB and SG offer survival benefits, with RYGB demonstrating a greater survival advantage in this simulated cohort.
Purpose:
For patients with obesity and congestive heart failure (CHF) who require heart transplantation (HT), aggressive weight loss has been associated with ventricular remodeling, or subclinical alterations in left and right ventricular structure that affect systolic function. Many have suggested offering metabolic and bariatric surgery (MBS) for these patients. As such, we evaluated the role of MBS in HT for patients with obesity and CHF using predictive modelling techniques.
Materials And Methods:
Markov decision analysis was performed to simulate the life expectancy of 30,000 patients with concomitant obesity, CHF, and 30% ejection fraction (EF) who were deemed ineligible to be waitlisted for HT unless they achieved a BMI < 35 kg/m2. Life expectancy following diet and exercise (DE), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed.
Results:
RYGB patients had lower rates of HT and received HT quicker when needed. Base case patients who underwent RYGB gained 2.2 additional mean years survival compared with patients who underwent SG and 10.3 additional mean years survival compared with DE. SG patients gained 6.2 mean years of life compared with DE.
Conclusion:
In this simulation of 30,000 patients with obesity, CHF, and reduced EF, MBS was associated with improved survival by not only decreasing the need for transplantation due to improvements in EF, but also increasing access to HT when needed due to lower average BMI.
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