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HEART TRANSPLANTATION MADE POSSIBLE THROUGH USE OF AN INTRAGASTRIC BALLOON
Andrew C. Storm*1, David B. Lautz2, Christopher C. Thompson1
1Brigham & Women's Hospital, Boston, MA; 2Emerson Hospital, Concord, MA
Background: Obesity is a leading risk factor for poor outcomes during and after solid organ transplantation. As such, a body mass index (BMI) of less than 30-35 m/kg2 is typically required to proceed with listing a patient for heart transplantation. Given the significant comorbidities and associated surgical risks for this patient population, minimally invasive and non-invasive weight loss strategies are needed.
Case: A 45-year-old man with idiopathic end-stage cardiomyopathy ultimately requiring left ventricular assist device (LVAD) on systemic anticoagulation with abixaban, BMI of 38.5 m/kg2 and brittle type 1 diabetes was initially determined to be a non-transplant candidate due to his morbid obesity. His end stage heart failure prevented exercise to accomplish weight loss. Endobariatric gastroenterology consultation offered intragastric balloon placement to assist in with weight loss to allow for BMI reduction and eventual cardiac transplantation. The patient was initiated on twice daily proton pump inhibitor and apixaban was held for 12 hours prior to upper endoscopy with cardiac anesthesia care, which was performed to rule out foregut pathology and to place a 600cc intragastric balloon. The balloon was left in place for 6 months, and removal was accomplished under full anticoagulation and LVAD support. Weight and metabolic parameters are shown and discussed below.
Results: Metabolic parameters including weight, BMI, hemoglobin A1c and calculated mean glucose values are shown below (Table 1). The patent’s weight progressively declined from 308 lbs to 259 lbs on IGB removal. BMI also decreased from 38.5 m/kg2 to 33 at balloon removal, allowing the patient to be listed for transplantation. The patient’s hemoglobin A1C decreased from 12.8 to 8.6 through the course of IGB therapy. Two months after IGB extraction, the patient underwent successful orthotopic heart transplantation. He remains well another 2 months after transplantation.
Conclusions: Patients with obesity and solid organ failure are at increased risk of complications during and after transplantation, and in cases of morbid obesity are not considered transplant candidates. In this case, an IGB was safely placed in a morbidly obese patient with end-stage heart failure requiring LVAD and systemic anticoagulation. The patient completed 6-month course of IGB therapy with improvement in metabolic and weight parameters allowing him to undergo successful heart transplantation within 3 months of IGB removal. Minimally invasive endobariatric techniques are a topic of research interest in patients with solid organ failure who are either non-transplant candidates or at risk for complications during and after transplant due to obesity.
Table 1: Metabolic parameters prior to and immediately after removal of the intragastric balloon
| | Immediately Pre-IGB | 3 months | 6 months (removal of IGB) | 10 months | | Weight | 308 | 289 | 259 | 248 | | BMI | 38.5 | 36.1 | 33 | 31 | | Hemoglobin A1C | 12.8 | 9.8 | 8.6 | 6.1 | | Calculated Mean Glucose | 321 | 235 | 200 | 128 |
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