These findings suggest that a MELD-XI score of 14 or higher was associated with a higher postoperative mortality rate than that seen in patients with a lower MELD-XI score. The MELD-XI scoring system can be used to predict outcomes in patients with advanced heart failure who undergo CF-LVAD implantation.

The purpose of this study was to analyze the effect of obesity on outcomes after continuous-flow left ventricular assist device (CF-LVAD) implantation. A single-center retrospective analysis was performed on 526 chronic heart failure patients who were implanted with the HeartMate II CF-LVAD (n = 403) or HeartWare HVAD (n = 123) between November 2003 and March 2016. Patients were stratified into 4 groups based on BMI: underweight (< 18.5 kg/m, n = 18, 3.4%), normal-weight (18.5-25 kg/m, n = 173, 32.9%), overweight (25-30 kg/m, n = 182, 30.2%), and obese (> 30 kg/m, n = 153, 33.5%). The underweight group was excluded because of its small sample size. Records were reviewed to determine the incidence of postoperative complications and survival. Survival at 1, 6, 12, and 24 months were similar among normal-weight (91.3, 84.4, 76.3, and 67.6%), overweight (90.4, 80.8, 76.5, and 69.6%), and obese patients (90.7, 74.7, 65.3, and 61.3%, p = 0.24). Additionally, obesity was not a significant predictor of mortality in Cox proportional hazard models (hazard ratio 0.98, 95% confidence interval 0.766-1.277, p = 0.13). These findings suggest that appropriately selected obese patients receive similar survival benefit from CF-LVADs compared to non-obese patients, and obesity should not serve as a contraindication to CF-LVAD implantation.

Left ventricular assist devices (LVADs) have become a preferred treatment option for patients with end-stage heart failure when used as a bridge to transplant or as a destination therapy. However, the association between small body size and postoperative outcomes for continuous-flow (CF) LVAD recipients is still being studied. We sought to determine whether body surface area (BSA) is associated with patient outcomes after CF-LVAD implantation. The study cohort of our single-center, retrospective review consisted of all patients (n = 526) who underwent CF-LVAD implantation (n = 403 HeartMate II, n = 123 HeartWare) between November 2003 and March 2016 regardless of indication. Patients were stratified into 2 cohorts according to their BSA measurements: small BSA (<1.5 m, n = 13) and non-small BSA (≥1.5 m, n = 513). We compared the survival of the small-BSA cohort with that of the non-small-BSA cohort. Patients with a small BSA had lower survival rates at 1, 6, 12, and 24 months (76.9, 61.5, 53.8, and 38.5%, respectively) than did patients with a non-small BSA (90.4, 80.9, 74.7, and 67.6% respectively; overall, p = 0.004). Cox proportional hazard analysis showed that a small BSA was an independent predictor of postoperative mortality (hazard ratio = 0.22, 95% confidence interval = 0.05-0.97, p < 0.04). These findings highlight the adverse impact of a small BSA on outcomes after CF-LVAD implantation.

ResponseWe thank Gokalp and colleagues for their thoughtful comments on our report. Our study found that obesity alone was not an independent risk factor for mortality in patients who underwent CF-LVAD implantation [1]. Other groups also have reported that obesity does not seem to be a risk factor for mortality in LVAD patients [2,3].We understand that much of the current data indicate that obesity increases mortality risk after cardiac surgery because of the co-factors that Gokalp et al. mention in their letter [4,5]. However, as we discuss in our report, obesity should not be an absolute contraindication for long-term implantable LVAD therapy.Our group of 120 obese patients (BMI > 30 kg/m 2 ) included a subset of 33 morbidly obese patients (BMI > 38.5 kg/m 2 ). In a Kaplan-Meier analysis ( Fig. 2 of our article) in which we compared the morbidly obese patients to all other patients (including those who were obese but not morbidly obese), we found significantly greater mortality in patients with morbid obesity (p = 0.049). In contrast, obesity of any degree (i.e., BMI > 30 kg/m 2 ) was not a significant independent predictor of postoperative mortality when all variables were placed in a multiple Cox proportion hazards model and subjected to stepwise regression analysis (hazard ratio = 0.98, 95% confidence interval 0.766-1.277, p = 0.13).At our center, we perform early extubation, discontinue the central line, and provide adequate nutritional support and aggressive occupational and physical therapy for obese patients to prevent complications such as pneumonia and infection [6]. This may be why our findings suggest that well-selected obese patients can receive a similar survival benefit from LVAD implantation as non-obese patients.

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