Amanda R. Vest

Bariatric surgery and cardiovascular outcomes: a systematic review

Purpose To quantify the impact of bariatric surgery on cardiovascular (CV) risk factors, and on cardiac structure and function. Data sources Three major databases (PubMed, Medline and Cochrane) were searched for original studies written in English. Study selection Original articles reporting CV risk factors or non-invasive imaging parameters for patients undergoing bariatric surgery, from January 1950 to June 2012. Data extraction Data extraction from selected studies was based on protocol-defined criteria that included study design, methods, patient characteristics, surgical procedures, weight loss, changes in CV risk factors, cardiac structure and cardiac function postoperatively. Data synthesis 73 CV risk factor studies involving 19 543 subjects were included (mean age 42 years, 76% female). Baseline prevalence of hypertension, diabetes and hyperlipidaemia were 44%, 24%, and 44%, respectively. Mean follow-up was 57.8 months (range 3–176) and average excess weight loss was 54% (range 16–87%). Postoperative resolution/improvement of hypertension occurred in 63% of subjects, of diabetes in 73% and of hyperlipidaemia in 65%. Echocardiographic data from 713 subjects demonstrated statistically significant improvements in left ventricular mass, E/A ratio, and isovolumic relaxation time postoperatively. Limitations Diagnostic criteria, CV risk factor reporting, and imaging parameters were not uniform across all studies. Study groups were heterogeneous in their demographics, operative technique and follow-up period. Conclusions This systematic review highlights the benefits of bariatric surgery in reducing risk factors for CV disease. There is also evidence for left ventricular hypertrophy regression and improved diastolic function. These observations provide further evidence that bariatric surgery enhances future CV health for obese individuals.

Surgical Management of Obesity and the Relationship to Cardiovascular Disease

The World Health Organization estimates that by 2015 the number of adults who are overweight (body mass index [BMI], 25.0–29.9 kg/m2) or obese (BMI ≥30 kg/m2) will surpass 1.5 billion.1 Excess body weight is an independent risk factor for mortality.2 Among the constellation of weight-related comorbidities that bring the greatest burden for obese patients and their healthcare providers are diabetes mellitus and cardiovascular disease (CVD). Obesity, diabetes mellitus, and CVD cannot be successfully addressed in isolation; therefore, weight loss achieved by any means is a key component of comprehensive cardiovascular care.3,4 Obesity prevention is the ideal scenario. However, in the midst of an obesity pandemic, treatment options are essential. The initial approach must always address lifestyle and dietary choices, which contribute so greatly to the current obesogenic environment. A healthy lifestyle is easily prescribed but challenging to maintain. Stalonas et al5 demonstrated not only that patients who diet usually regain their lost weight within 5 years but also that the average subject was 1.5 lb heavier at follow-up than on entering the program. A recent systematic review of dietary and lifestyle options demonstrated no conclusive evidence for sustainable weight loss.6 However, it is possible for intensive lifestyle coaching to achieve moderate weight loss, as demonstrated by Appel et al.7 Of their 392 obese subjects, those receiving in-person support lost a mean of 5.1 kg ( P <0.001 for comparison with control subjects) and those receiving only telephone/Internet support lost a mean of 4.6 kg ( P <0.001 for comparison with control subjects) at 24 months. The superiority of bariatric surgery over pharmacological and lifestyle interventions in modulating weight, hyperglycemia, and hypertriglyceridemia has been demonstrated by meta-analysis.8 Few studies have directly compared medical and surgical management of obesity, but 2 head-to-head comparisons …

Outcomes for Patients With Diabetes After Continuous-Flow Left Ventricular Assist Device Implantation

BACKGROUND Diabetes mellitus (DM) is a risk factor for mortality among patients with heart failure as well as for patients who undergo cardiothoracic surgery. However it is unknown whether DM is associated with increased mortality or major complications during continuous-flow left ventricular assist device (CF-LVAD) support. METHODS AND RESULTS We retrospectively reviewed 300 consecutive adults who received CF-LVADs at a single center in the years 2006-2013; 129 patients had DM before LVAD, as defined by American Diabetes Association criteria (HbA1c ≥6.5% and/or taking DM medications). Compared with the non-DM group, DM patients were older, with a higher pre-LVAD body mass index, more ischemic heart failure etiology, and higher pre-LVAD creatinine. Ninety-three patients died on LVAD support, 43 with DM and 50 without DM (P = .4526). After control for 9 covariates in a Cox proportional hazards model, DM was unassociated with all-cause mortality (hazard ratio 0.883, 95% confidence interval 0.571-1.366; P = .5768). Diabetes was also unassociated with the adverse event end points of stroke/transient ischemic attack, intracerebral hemorrhage, pump thrombosis, and device-related infections. CONCLUSIONS Diabetes is common in LVAD recipients (43% of the present cohort) but does not increase mortality or rates of major adverse events during CF-LVAD support.

Concerning the Role of Gender Difference in Obesity Paradox in Patients With Heart Failure.

We thank Dr. Emami and colleagues for their interest in our paper on a differential effect of excess adiposity in female and male subjects. We agree that selecting model covariates to adjust sufficiently for baseline differences between the sexes, without overfitting the model, was one of the most

49 Cardiovascular Disease in the Bariatric Surgery Patient

Obesity is a strong risk factor for the development of type 2 diabetes, hypertension, dyslipidemia, and cardiovascular disease (CVD). Diet, exercise, and drug therapies have limited potential to achieve significant and sustainable weight loss. Bariatric surgery has emerged as the most successful long-term strategy both in achieving weight loss and in promoting diabetes, hypertension, and hyperlipidemia remission. The malabsorptive procedures, including Roux-en-Y gastric bypass and biliopancreatic diversion, appear particularly effective in achieving diabetes remission. This impact on CVD risk factors appears to translate to a decrease in actual cardiovascular events for obese patients who have undergone bariatric surgery, with very preliminary data suggesting atherosclerosis regression. There is also some evidence to support a mortality benefit after surgical weight loss. In addition, there is now data demonstrating improvement of obesity-associated abnormalities in myocardial structure and function, such as ventricular hypertrophy, diastolic dysfunction, and subclinical systolic dysfunction, after bariatric procedures. The impact of bariatric surgery on heart failure is an area of current investigation.

THE SURVIVAL ADVANTAGE OF FEMALE GENDER IN SYSTOLIC HEART FAILURE IS RESTRICTED TO FEMALES WITHOUT CORONARY ARTERY DISEASE

results: Compared to males, females were younger (52.2±12.3 vs 54.4±11.9), lower in BMI (27.8±6.3 vs 28.6±5.3 kg/m2), had higher ejection fractions (22.8±9.1 vs 21.6±8.7%) and lower CAD prevalence (28.1 vs 54.8%), all p<0.0001. Unadjusted mortality at 81.6±59 months was 39.1% (32.0 females vs 41.7% males, p<0.0001). After adjustment for demographics, comorbidities, drugs and VO2 max (overall model χ2 725.5), there was a significant interaction between gender and CAD status (χ2 23.5, p<0.0001) as illustrated by Figure 1. Figure 2 illustrates the weaker interaction between gender and BMI (χ2 3.10, p=0.078), whereby increasing BMI associates with increased adjusted mortality risk in males, but not females, with systolic HF.

BARIATRIC SURGERY IS ASSOCIATED WITH LEFT VENTRICULAR EJECTION FRACTION IMPROVEMENT IN OBESE PATIENTS WITH SYSTOLIC HEART FAILURE

introduction: Obesity is one of the most important public health challenges and an established risk factor for incident heart failure (HF). Bariatric surgery has the potential to achieve marked weight loss and also remission of diabetes, dyslipidemia and hypertension. However it remains unclear whether significant improvements in left ventricular ejection fraction (LVEF) can be expected after bariatric surgery in systolic HF patients.

Hemopericardium, shock, and a linear density in the ascending aorta: is it a dissection?

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 67-year-old man with a Starr-Edwards aortic valve replacement and known stable ascending aortic aneurysm presented with chest pain radiating to the back, tachycardia, hypotension, and a supratherapeutic international

Hypertension in Pregnancy

Hypertension in pregnancy is diagnosed on systolic blood pressure greater than or equal to 140 mm Hg and/or diastolic greater than or equal to 90 mm Hg. The classification systems separate chronic and gestational hypertension from preeclampsia. Significant uncertainty regarding optimal management is reflected in the differing major international society recommendations. Blood pressure treatment is designed to minimize maternal end-organ damage. Methyldopa, labetalol, hydralazine, and nifedipine are oral options; angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated. Women with preeclampsia should be closely monitored and receive intravenous magnesium sulfate.