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High Risk Cardiac Patients and Bariatric Surgery

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									                                                                                Disclosure
                                                   • I  receive funding from Medtronic, St. Jude, Pfizer, United Therapeutics, 
                                                     Actelion (not enough)

High Risk Cardiac Patients                         • I will clearly identify off‐label usage of drugs or devices


  and Bariatric Surgery
           Marc R. Pritzker, M.D.
  Professor of Cardiovascular Medicine and 
                   Surgery




                                              Cancer:                                       Stroke    Daytime sleepiness/sleep apnea
                                              Breast, ovary, cervix,                                       Impaired breathing
                                              endometrium (women)
                                              esophagus                                                    Heart disease

                                              kidney                                                       Pancreatitis

                                              gall bladder                                                 Kidney stones and disease

                                              nonHodgkins disease                                          Liver disease

                                              stomach and prostate (men)                                   Gallbladder disease

                                              colorectal                                                   Carpal tunnel syndrome
                                                 Type 2 Diabetes                                           Low back pain

                                              High blood cholesterol                                       Pain
                                                                                                           Urinary stress incontinence
                                                                                                           Surgical complications

                                              High blood pressure                                          Infections following wounds
                                                                                                           Infertility
                                                                                                           Impaired immunity
                                                 Health Dangers                                            Osteoarthritis
                                                of Excess Weight                                           Gout




                                                                                                     6:19-
                                                                                      I Corinthians 6:19-20, “What? know ye not
                                                                                      that your body is the temple of the Holy
                                                                                      Ghost which is in you, which ye have of God,
                                                                                      and ye are not your own? For ye are bought
                                                                                      with a price: therefore glorify God in your
                                                                                                                          God’
                                                                                      body, and in your spirit, which are God’s.”
Changing the prognosis for high                           “Diseased nature oftentimes breaks forth in strange eruption “
                                                         “I have more flesh than another man, and therefore more frailty”
      risk obese patients                                                            Falstaff

                                                                            •   Sleep apnea
                                                                            •   Diabetes
                                                                            •   Nutrition
                                                                            •   Smoking
                                                                            •   Lipids
                                                                            •   ASHD
                                                                            •   Hypertension
                                                                            •   Heart Failure




  Complications by VO2max




                        CHEST / 130 / 2 / AUGUST, 2006
                                                                                                         Months Before
                                                                                                          Boot Camp
                                   Obesity
                                                                                 Start statin drugs to reduce inflammatory mediators

                                                                                 Re-evaluate for OSA and efficacy of therapy
             Adiposity                       AGE/RAGE         Triglyceride
                                                                                 Diet and diet journal

Neurohormone Inflammatory      Cytokine       NADPH                FFA           Exercise, Exercise, Exercise
  Increase     Infiltrate     Chemokine        oxidase
                                                                                 Aggressive control of blood sugar and pressure
             Macrophage          TNF                          PKC Activation
                                                                                 Consider PDE V inhibitor to improve endothelial function and reduce
             Lymphocytes          IL-6                           AKT
             Dendritic Cell                  NO + O-          Phosphorylatinon
                                                                                 inflammatory mediators
                                 MCP1
                                  IL-8                                           Inspiratory muscle training




         Things I Have Learned From My
                    Children
                                                                                                                  ?

     Garbage bags do not a parachute make.

     When one hears the toilet flush and “uh oh” it is already too
     late.

     Superglue is forever.

     VCR’s don’t eject PB&J sandwiches even though they do on
     television.

     There are potential veterinary applications to obesity




    NASA Rig for Rehabilitating Horse
              and Humans
      Non-invasive Imaging for CAD                                                                                                Stents
  Conventional image enhanced stress testing confounded by                                  Uncoated metal stents require two months of ASA/Plavix before 
logistics, poor resolution, and attenuation in the mobidly obese                            suspending them for procedure
patient. High equivocal rate.
                                                                                            DES require 1 year of ASA/Plavix before suspension
  Transesophageal echo with dobutamine stress may solve many of
these problems, but caution is necessary in patients with impaired
                                                                                            Following surgery Plavix +/‐ ASA should be resumed on post‐operative 
respiratory status especially those with obesity hypoventilation
syndrome.
                                                                                            day 2 as the patients are hypercoagulable

  PET scanning allows for better resolution and imaging but is very
$ intensive.

  Coronary arteriography via radial approach safe and definitive

  Don’t know if intervention reduces risk of surgery




                                                                                              Perioperative Cardiac Morbidity And 
                                                                                                    Mortality By CAD Status
                 Patient Selection CAD

   History of coronary revascularization

   Coronary artery stenosis > 30% in one or more major arteries

   Inducible ischemia

   History of myocardial infarction



                             52 of 567 patients in series



                                                                                                                                                                                 Mayo Clinic Proc.
                                                                                                                                                                                 2005

                                                   Mayo Clinic Proc 2005: 80(9) 1157    Mayo Clinic Proc. 80 (9) 1157,2005




               Effect of Bariatric Surgery on                                                Bariatric Surgery in MO Patients with 
                  Modifiable Risk Factors                                                     Severe Systolic Heart Failure( n=12)
                                                                   Reduced insulin                                       baseline                           12mos
                                                                   resistance               BMI                          53.7                                   38.8
                                                                   Reduced oxidative                                                                                   LAPRY      8
                                                                   stress                   Non‐ischemic                 10                                            LapSL      2
                                                                                                                                                                       LapGB 1
                                                                                            Inotropes                        2                                         OpenRY 1
                                                                                            OSA                              6                                5

                                                                                            Afib                             6I
                                                                                                                                                                       Mortality    0
                                                                                            Na                           138                                           PulEdema 1
                                                                                                                                                                       ARF              1   
                                                                                            NYHA                             2.9

                                                                                            LVEF                    22                                35

                                                                                            LVEDD                        6.4                                  5.5             Clin.Card: 31(11)515,2008
Mayo Clinic Proc. 80 (9) 1157,2005
    ANW CHF & Bariatric Surgery                                                 CHF & Bariatric Surgery Pre-op

       N=6                                                                      All patients admitted to CCU and underwent right heart catherization
                                                                                and optimization of cardiac output and filling pressures with
                                                                                milrinone or sodium nitroprusside and diuretics. Target wedge 15-18
       BMI mean 48       (weight 330-600)
                                                                                as pneumoperitoneum or Trendelenburg produce hypovolemic
                                                                                hypotension
       Ejection Fraction 22%
                                                                                If transpulmonary gradient greater than 15 patients were evaluated
       LOS average 7 days                                                       with prostacyclin or sildenafil

       Etiology: non-ischemic                                                   All patients were started on statin for cytokine modification

                                                                                Inspiratory muscle training begun pre-operatively prior to admission
       Complications: leaks 0, prolonged intubation 1,
                                                                                CVP was manipulated to < 12 to minimize bleeding complications
       Mortality 0                                                              from high CVP

                                                                                Overnight recording oximetry performed to assess efficacy of OSA
                                                         Pritzker unpublished   treatment and altered as necessary

                                                                                Blood sugars corrected to < 150




           Effect of Bariatric Surgery on NYHA 
             Functional Classification in CHF


                                                                                       Diseases desperate grown are rescued by 
                                                                                           desperate measures or not at all




                                                                                                           Multivariate Risk for Mortality in Obesity

                        We’re Getting Bigger




                                                                                Calle E et al. N Engl J Med 1999;341:1097-1105
JAMA 288(14)1759 2002
                             Weight



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