Management of obesity in the contemporary LVAD era

Obesity is a defining comorbidity in durable left ventricular assist device (LVAD) supported patients, driven in part by transplant listing policies that consider body mass index (BMI) ≥35 kg/m2 a relative contraindication to heart transplantation. In the contemporary LVAD era, obesity is no longer associated with excess early or intermediate-term mortality. Instead, it functions as a morbidity amplifier and a barrier to definitive therapy, contributing to higher rates of device-related complications, healthcare utilization, and reduced access to transplantation. Importantly, clinically meaningful weight loss during LVAD support is uncommon, with fewer than 20% patients achieving 10% weight loss, typically insufficient to restore transplant eligibility. Lifestyle and exercise interventions in LVAD supported patients improve quality of life but rarely produce transplant-enabling weight loss. Pharmacological therapies, particularly incretin-based agents, have demonstrated promising weight-loss efficacy in observational LVAD cohorts, with acceptable short-term tolerability. However, LVAD-specific prospective safety and effectiveness data are lacking, and experience in heart failure with reduced ejection fraction has raised cautionary signals. Bariatric surgery, most commonly laparoscopic sleeve gastrectomy, reliably induces weight loss and may increase transplant listing and transplantation rates in selected patients, but is accompanied by high perioperative morbidity and is supported exclusively by observational data from selected cohorts. This perspective reviews contemporary evidence for obesity management during LVAD support, emphasizing therapeutic trade-offs, limitations of existing data, and unresolved clinical and policy questions. Development of structured, stepwise treatment pathways and generation of LVAD-era data are essential to improve transplant access and outcomes in this growing patient population.