Laparoscopic Vertical Sleeve Gastrectomy (LVSG) in a patient with Dilated Cardiomyopathy with a Left Ventricular Assist Device (LVAD)

Pornthep Prathanvanich, DO, Bipan Chand, DO. Loyola University Chicago Stritch School of Medicine.

Background: A ventricular assist device (VAD) provides cardiac output in patients with severe cardiac dysfunction. This surgically implanted pump delivers blood from the left ventricle to the aorta and may also provide a bridge to cardiac transplantation. We report a case of a morbidly obese patient undergoing successful LVSG with a LVAD in place.

Method: This 42 year old female developed postpartum dilated cardiomyopathy (DCM) at the age of 26. Despite medical management, she progressed to class IV CHF requiring home inotropic support and eventually underwent LVAD implantation. The patient’s functional capacity increased. However given her morbid obesity (BMI = 54.73 kg/m2) she was ineligible for transplantation. The patient also suffered with metabolic syndrome including hypertension, DM and central obesity as well as OSA requiring CPAP. Preoperative imaging included abdominal computed tomography demonstrating LVAD components in close proximity to the right and left subcostal region and left lobe of the liver.

Result: Preoperative echocardiogram revealed 4-chamber enlargement, mild pulmonary hypertension and a left ventricular ejection fraction of 5%. Operative planning included arterial line and two large bore IVs. The drive of the LVAD was prepped in the operative field and the pump was on and monitored for output throughout the procedure. Sleeve gastrectomy was performed laparoscopically using a four port technique. Diagnostic laparoscopy revealed the drive to be going intraperitoneal with the pump obliterating the space above the left lobe of the liver. Liver retraction was obtained with surgical sponges. After identification of the pylorus, mobilization of the greater curvature was undertaken all the way to the angle of His. A 40-Fr bougie facilitated creation of the sleeve without narrowing the incisura. The staple line was over sewn.
The operative time was 75 minutes and blood loss was 10 ml. Postoperative pain score (VAS) was 4 of 10. There were no perioperative complications, no congestive heart failure.

Conclusion: Laparoscopic sleeve gastrectomy can be safely performed in morbidly obese patients with DCM and LVAD. These procedures require an extensive preoperative preparation, close intraoperative monitoring and a clear understanding of the physiologic changes associated with the LVAD and laparoscopic surgery as well as dedicated VAD personnel , and continuous communication amongst team members.

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