Disclosures: Yi Zhou, MD: No financial relationships or conflicts of interest

Case Diagnosis: A 25-year-old woman with morbid obesity and a left ventricular assist device (LVAD) who underwent sleeve gastrectomy

Case Description or Program Description: She has a MAP goal of 70-90 mmHg and a goal international normalized ratio (INR) of 2.0-2.5. She was stabilized on 20 mg of warfarin daily for the past month.

The patient underwent elective bariatric surgery to lower body mass index for heart transplant considerations. She was sent to acute cardiac rehabilitation for continued risk management and to improve mobility.

Setting: Inpatient cardiac rehabilitation

Assessment/Results: During acute cardiac rehabilitation there were reductions in warfarin requirements and mean arterial pressure. Compared to her 20mg warfarin daily maintenance dose, there was a substantial reduction of almost 50% to 10.2mg daily. Likewise, her average mean arterial pressures were often below her usual 80-90 mmHg range. Her amlodipine to be discontinued. Bumetanide was held multiple days due to MAP readings in the 60-70 mmHg range and gradually reintroduced and uptitrated to home dosing when met with clinical signs of hypervolemia such as shortness of breath, increasing weight, and lower extremity swelling.

By discharge, the patient was able to be stabilized on a 10mg daily warfarin dose and with MAPs consistently in her 70-90 mmHg MAP goal. She was discharged home at an independent level and to continue outpatient cardiac rehabilitation.

Discussion (relevance): To our knowledge, there are no reported cases of cardiac rehabilitation management for LVAD patients post-bariatric surgery. There are numerous proposed mechanisms to explain changes in warfarin requirement and blood pressure post-bariatric surgery. Close monitoring and risk management are important factors in caring for the LVAD patient following bariatric surgery.

Conclusions: Acute cardiac rehabilitation in the postoperative period is not only crucial to improve function but also for medical optimization as these patients require adjustments in cardiac medications and daily monitoring to prevent complications.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/cardiac-rehabilitation-risk-management-of-patient-with-left-ventricular-assist-device-after-bariatric-surgery-a-case-report/