Banner Health eases heart transplant process for obese patients

Dr. Radha Gopalan, a cardiologist at Phoenix-based Banner Health, was disturbed by a growing trend in his practice in which young, obese patients were dying from heart failure. 

Their deaths were the result of an awful predicament. These patients had heart failure so advanced they required a heart transplant, but they were ineligible because their body mass index was higher than 35, the cutoff for the procedure to be performed safely at most transplant centers. 

At the same time, weight loss through diet and exercise is usually impossible for these patients and most bariatric surgeons refuse to perform surgery on heart failure patients because of the high risk of complications. 

As a result, these patients “have no way of extending their lives,” Gopalan said, and because the problem is likely to only get worse given the predicted continued rise of obesity in the U.S., he was motivated to look for a solution. 

So soon after joining Banner in mid-2017, Gopalan approached his colleague Dr. Robin Blackstone, who leads the Banner-University Medicine Obesity and Bariatric Surgery Center, with the idea of working together to help these patients become eligible for heart transplants by performing bariatric surgery to reduce their BMI. She agreed, albeit warily. Because the procedures aren’t done routinely or supported by research, they’re risky.

“There was caution on my part,” Blackstone said. “It was really important to me to communicate with the patient, so they understand where we are in our state of knowledge about this.”

In the nearly two years since their teams started working together, they have performed bariatric surgery on 28 patients, all with positive outcomes, and hope their experiences can spur more research and eventually change standard practice. Banner is the only provider in the U.S. with an established program focused on offering bariatric surgery to heart-failure patients. 

“We are starting to get a glimpse into research that could eventually look at obesity in these patients differently,” Blackstone said.

The plan Gopalan and Blackstone devise for each patient depends on their individual situation. For patients with a BMI between 35 and 45, Gopalan’s team will usually insert a left ventricular assist device (LVAD) into the patient. The device, which assists heart function, allows the patient to safely undergo bariatric surgery by Blackstone and her team because the heart has extra support, lowering the risk of an adverse outcome. Banner waits about six months after the device is inserted to do the bariatric surgery to ensure it’s effectively supporting the patient’s heart. 

Four patients have undergone this treatment path and have since reached a BMI of 35, making them eligible for a transplant, Gopalan said. 

He added that bariatric surgery is still necessary for patients who get an LVAD because even with improved heart function it’s still too hard to lose weight through diet and exercise. 

Another treatment plan is for patients with a BMI higher than 45. It’s too risky for them to undergo the surgery needed to insert an LVAD, so Gopalan strengthens their heart with medications for about two to four days on average, until it’s safe for them to undergo bariatric surgery. 

The patient’s heart is monitored by the team in the days leading up to the surgery to ensure it’s safe to perform. Gopalan is also present during the procedure to monitor the heart. 

Twenty-four patients have received this treatment plan. They have either become eligible for a heart transplant or no longer need one, Gopalan said. “In patients who had moderate cardiac dysfunction, their cardiac function has normalized after they have lost weight,” he added. 

Along with Gopalan and Blackstone’s physicians and nurses, a dietitian and psychologist are also part of the program. The dietitian meets with the patients in the months before and after the bariatric surgery to help them maintain healthy eating habits. 

Of the need for a psychologist, Blackstone said, the patients “have been very ill for a long time and it limits their participation in the lives of their families. We are integrating them into a full family life after (surgery); that is not an inconsiderable task.”