E. Hauptmann2, R. Whitlock1, S. Yeganeh1, J. Ehab2, M. Thornton1, M. Jessen1, C. Heid1, M. Peltz1 1University Of Texas Southwestern Medical Center, Cardiothoracic Surgery, Dallas, TX, USA 2University Of Texas Southwestern Medical Center, General Surgery, Dallas, TX, USA
Introduction: Morbid obesity in patients has well published increased rates of perioperative morbidity and mortality, which can pose significant challenges for surgeons. Left ventricular assist device (LVAD) insertion utilizing a sternal sparing approach (ssLVAD) has been adopted as a less invasive approach which avoids the morbidity of median sternotomy for patients with heart failure. However, patients with morbid obesity may present increased challenges in pursuit of this minimal access operation. We present our experience with ssLVAD in patients with WHO class 2 or greater obesity.
Methods: A single center retrospective review of durable ssLVADs implanted between 2019 and 2024 was performed. Patients were stratified by the presence of WHO obesity defined as grade 2 (BMI > 35 kg/m2). Pre, intra, and post-operative variables were compared using Fischer’s exact and Mann-Whitney U tests for categorical and continuous variables, respectively. A composite outcome was created, including the presence of post-operative right ventricular failure, death from any cause, or stroke. Survival analysis was performed using the Kaplan Meier method.
Results: A total of 83 patients were identified during the study period. Across all patients, a total of 28 (33.7%) were identified as having a BMI greater than 35 kg/m2. Seventy-six percent of patients were male, and the median age of the cohort was 55 years old at time of insertion. Median BMI amongst WHO grade 2 obese patients was 39 kg/m2 as compared to 26 kg/m2 of non-obese patients (p<.001). Of all LVAD insertions performed during the study period, 65 (78%) were performed as destination therapy while 16 (19%) were inserted as bridge to transplant. However, there was no difference in LVAD indication between obese and non-obese recipients (p=.2). There were no differences in rates of preoperative renal failure, diabetes, liver disease, hypertension, or peripheral vascular disease between cohorts. Obese patients experienced longer overall operative time (6.38 vs 5.57 hours, p=.005) and trended towards longer cardiopulmonary bypass times (132 vs 114 minutes, p=.06) than non-obese patients. There were no differences in rates of intraoperative blood transfusions, post-operative ICU time, ventilator time, or post-operative complications. Thirty-day survival among all recipients was 100%. There were no statistical differences in incidence of the composite outcome amongst patients with BMI > 35 (36%) vs BMI < 35 (64%) (p=.7).
Conclusion: In obese patients, although ssLVAD may be more technically challenging and appeared to be associated with increased overall operative time compared to the median sternotomy approach, this did not affect recipient outcomes. Sternal sparing LVAD is a safe surgical option in WHO Class 2 obese patients with the added benefit of avoiding historical surgical morbidity of median sternotomy.