Use of an intra-aortic balloon pump during laparoscopic sleeve gastrectomy

Introduction

Heart failure (HF) affects approximately 5.7 million adults in the United States with 5-year mortality approaching 50%^[1]. Heart transplantation is the standard management for advanced HF. However, a body mass index (BMI) ≥ 35 kg/m² is associated with increased early complications, decreased long-term survival, and lower likelihood of receiving an organ^[2,3]. Weight loss results in decreased vascular stiffness and reduction in ventricular hypertrophy^[4]. Bariatric surgery in patients with advanced HF may result in eligibility for heart transplantation. We report the use of an intra-aortic balloon pump (IABP) for perioperative cardiovascular support during laparoscopic sleeve gastrectomy (LSG) in a patient with advanced HF.

Case report

A 43-year-old patient with non-ischemic cardiomyopathy, New York Heart Association (NYHA) Class IIIb, and morbid obesity (BMI 45 kg/m²) was referred for weight loss prior to evaluation for heart transplantation. Co-morbid conditions included obstructive sleep apnea, nonalcoholic steatohepatitis, gastroesophageal reflux disease, hyperlipidemia, exertional hypotension, adrenal insufficiency, and 3L continuous oxygen. The patient was diagnosed with HF three years prior with an ejection fraction (EF) of 15%-20%, which required an implantable cardioverter-defibrillator (ICD). Titration of antihypertensive and diuretic medications was limited by syncope and hypotension. The patient was hospitalized over thirteen times with episodes of HF exacerbation and arrhythmias. Ultimately, the ICD was converted to a biventricular device, and EF improved to 25% with complete ventricular pacing. Our patient did not qualify for left ventricular assist devices (LVAD), but still, weight loss surgery was recommended to improve cardiac function and increase the potential for candidacy for heart transplant.

Discussion

Obesity is a risk factor for the development of cardiovascular disease and HF. Heart transplant is the primary treatment for end-stage HF; however, morbid obesity is a relative contraindication to transplantation^[8]. A BMI ≥ 35 kg/m² is associated with early complications and decreased long-term survival after heart transplant, compared to class I obesity^[2]. Weight loss improves cardiovascular function through increased left ventricular diastolic and systolic function, reduction of myocardial oxygen consumption, and reversal of impaired aortic distensibility^[4]. The Swedish Obese Subjects study demonstrated sustained weight loss and decreased cardiovascular events, including death, after bariatric surgery^[9]. Thus, bariatric surgery is an effective intervention for morbidly obese patients who require weight reduction to become a candidate for heart transplantation.

Bariatric surgery in patients with severe cardiomyopathy, including LVAD, is an opportunity for rapid weight loss as a “bridge” to transplantation. Studies of small cohorts show patients with LVAD who underwent bariatric surgery had improvement in median left ventricular ejection fraction and reduction in NYHA classification^[6,10]. In particular, Punchai et al.^[6] reported on three patients with LVAD who went on to receive a heart transplant after LSG. Acceptable rates of complications included five perioperative morbidities and two deaths from LVAD complications. LVAD complications occur at a rate of 8%-29% and include: bleeding, infection, neurologic event, and anticoagulation issues^[11]. In addition, mechanical circulatory support devices are associated with heightened healthcare costs. The total cost for LVAD as a bridge to transplantation ranges from $316,078 to $1,025,500^[12]. Further cost of management includes the median cost of a single readmission at $7,546; with up to 81.8% of LVAD patients requiring readmission^[12]. Options for our patient were to perform weight loss surgery: (1) after further deterioration that required LVAD implementation or (2) with the option of temporary mechanical support with IABP. The early intervention of LSG improved cardiac function and symptoms for more than one year although, an episode of cardiogenic shock ultimately required LVAD placement. While the progression to LVAD is an acceptable risk, this case describes the multidisciplinary team approach critical to successful LSG in a patient with complex heart disease.

To the best of our knowledge, this is the first report of the temporary use of an IABP to achieve uncomplicated bariatric surgery in a high-risk patient with advanced cardiac disease. The IABP has been utilized to establish hemodynamic stability in patients awaiting cardiac surgery with decompensated HF^[13], but rarely reported in non-cardiac surgery. Successful placement of an IABP in patients with congestive HF who underwent non-cardiac procedures (nephrectomy, colectomy with splenectomy, and an exploratory laparotomy) potentially reduced morbidity and mortality^[14]. Similarly, the temporary mechanical circulatory assistance of the IABP resulted in a successful LSG, without morbidity or mortality. As a result, the multidisciplinary team approach resulted in safe bariatric surgery, in a hospital with the infrastructure to manage advanced HF.

In conclusion, the temporary application of an IABP provides cardiovascular support to achieve a safe LSG. A multidisciplinary team approach is recommended for perioperative management of advanced HF.