Background We investigated preoperative referral patterns, rates of cardiovascular testing, surgical wait times, and postoperative outcomes in White versus Black, Hispanic, or other racial or ethnic groups of patients undergoing metabolic and bariatric surgery. Methods and Results This was a single center retrospective cohort analysis of 797 consecutive patients undergoing metabolic and bariatric surgery from January 2014 to December 2018; 86% (n=682) were Black, Hispanic, or other racial or ethnic groups. White versus Black, Hispanic, or other racial or ethnic groups had similar baseline comorbidities and were referred for preoperative cardiovascular evaluation in similar proportion (65% versus 68%, P =0.529). Black, Hispanic, or other racial or ethnic groups of patients were less likely to undergo preoperative cardiovascular testing (unadjusted odds ratio [OR], 0.56; 95% CI, 0.33–0.95; P =0.031; adjusted for Revised Cardiac Risk Index OR, 0.59; 95% CI, 0.35–0.996; P =0.049). White patients had a shorter wait time for surgery (unadjusted hazard ratio [HR], 0.7; 95% CI, 0.58–0.87; P =0.001; adjusted HR, 0.7; 95% CI, 0.56–0.95; P =0.018). Reduction in body mass index at 6 months was greater in White patients (12.9 kg/m 2 versus 12.0 kg/m 2 , P =0.0289), but equivalent at 1 year (14.9 kg/m 2 versus 14.3 kg/m 2 , P =0.330). Conclusions White versus Black, Hispanic, or other racial or ethnic groups of patients were referred for preoperative cardiovascular evaluation in similar proportion. White patients underwent more preoperative cardiac testing yet had a shorter wait time for surgery. Early weight loss was greater in White patients, but equivalent between groups at 12 months.

Introduction: Candidates for bariatric surgery are at increased risk for cardiovascular disease and often develop adverse cardiac remodeling as a result of obesity. Bariatric surgery can alter cardiac structure and function in these patients; however, this has not been fully investigated. Hypothesis: We hypothesized that patients undergoing bariatric surgery would demonstrate favorable cardiac remodeling and improvement in diastolic parameters according to the American Society of Echocardiography (ASE) guidelines. Methods: All patients undergoing bariatric surgery at our institution from 2014-2018 were reviewed. In patients with pre- and post-operative echocardiograms, the following were measured: left ventricular (LV) size, pulmonary artery systolic pressure (PASP), LV mass, mitral E/A, LV ejection fraction (EF), medial and lateral E/e’, medial e’ and a’, lateral e’ and a’, tricuspid regurgitation (TR) velocity, left atrial volume index (LAVI), degree of LV hypertrophy, and relative wall thickness (RWT). The grade of diastolic dysfunction (DD) was calculated according to ASE guidelines. Results: A total of 69 patients met criteria for inclusion, with 77% (n=53) female, 87% (n=60) non-white, and mean age 49±10.7. Mean decrease in BMI one year post-operatively was 14.6±5.7 kg/m 2 . Median time between bariatric surgery and post-operative echocardiogram was 21.8 months. Post-operatively, there was a mean 17.8 cm/s decrease in TR velocity (p=0.0064) and 4.2 mmHg decrease in PASP (p=0.02). LAVI increased by 3.4 mL/m 2 (p=0.048). There was no significant change in LV size, LV mass, LVEF, LV hypertrophy, or RWT. Out of the 29 patients with pre-existing DD (grade 1, n=20; grade 2, n=8; grade 3, n=1), 45% (n=13) demonstrated improvement in grade of DD. When compared to pre-operative DD, post-operatively, 5 of 20 patients with G1DD had no DD, 2 of 8 patients with G2DD had no DD, 5 of 8 patients with G2DD had G1DD, and 1 patient with G3DD had G1DD. This was driven by a decrease in TR velocity and medial E/e’. Conclusions: In patients undergoing bariatric surgery, TR velocity and PASP improved while LAVI paradoxically increased. Patients with pre-existing DD demonstrated improvement in diastology, driven by changes in TR velocity and medial E/e’.

Introduction: Candidates for bariatric surgery are at increased risk for cardiovascular disease, which may increase surgical risk. Currently, there are no society guidelines indicating which patients are appropriate for preoperative cardiovascular evaluation and risk stratification. Hypothesis: We hypothesized that applying a standardized surgical risk calculator with a novel multidisciplinary internal referral algorithm to stratify patients for preoperative cardiovascular evaluation would decrease unnecessary referrals and cost. Methods: All patients undergoing bariatric surgery at our institution between 2014-2018 were identified. After assessing baseline patient characteristics, referral patterns to cardiology, prevalence of cardiac testing ordered, and surgical outcomes were measured. The Revised Cardiac Risk Index (RCRI) score was retrospectively calculated for each patient and grouped as low versus increased risk (RCRI score of 0 versus ≥ 1). Imputing a post hoc referral algorithm requiring an RCRI ≥ 1, age ≥ 65, METS ≤ 4, and/or ever smoking history for cardiology referral, we calculated how referral pattern would be affected and the resultant change in referral costs. Results: A total of 797 patients underwent bariatric surgery during the study period, of which 68% (n=540) were referred to cardiology preoperatively. Those referred had more hypertension, hyperlipidemia, diabetes, smoking history, and were more likely to have BMI >50 kg/m 2 . Of those referred, 81% (n=438), 15% (n=81), 3% (n=17), and 1% (n=4) had RCRI scores of 0, 1, 2, and ≥ 3, respectively. Of those patients with an RCRI score of 0, 53% (n=234) underwent further cardiac testing. Strictly applying our standardized internal referral algorithm, of the 540 patients referred to cardiology, only 45% (n=199) were appropriately referred. Based on Medicare reimbursement for Level 4 outpatient consults, this would have resulted in a savings of approximately $86,000. Conclusions: Among candidates for bariatric surgery, a novel referral algorithm based on RCRI and other cardiovascular risk factors may reduce unnecessary preoperative cardiology referrals, with resultant reduction in resource utilization and overall cost savings.