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Observational Study
. 2022 Oct 18;80(16):1501-1512.
doi: 10.1016/j.jacc.2022.08.738.

Long-Term Changes in Cardiac Structure and Function Following Bariatric Surgery

Hidemi Sorimachi  1 , Masaru Obokata  1 , Kazunori Omote  1 , Yogesh N V Reddy  1 , Naoki Takahashi  2 , Katlyn E Koepp  1 , Arnold C T Ng  3 , Oliver J Rider  4 , Barry A Borlaug  5
Affiliations
Observational Study

Long-Term Changes in Cardiac Structure and Function Following Bariatric Surgery

Hidemi Sorimachi et al. J Am Coll Cardiol. .

Abstract

Background: Studies with short-term follow-up have demonstrated favorable effects of weight loss (WL) on the heart, but little information is available regarding long-term effects or effects of visceral fat reduction.

Objectives: The purpose of this study was to evaluate the effects of long-term WL following bariatric surgery on cardiac structure, function, ventricular interaction, and body composition, including epicardial adipose thickness and abdominal visceral adipose tissue (VAT).

Methods: A total of 213 obese patients underwent echocardiography before and >180 days following bariatric surgery. Abdominal VAT area was measured by computed tomography in 52 of these patients.

Results: After 5.3 years (IQR: 2.9-7.9 years), body mass index (BMI) decreased by 22%, with favorable reductions in blood pressure, fasting glucose, and left ventricular (LV) remodeling in the full sample. In the subgroup of patients with abdominal computed tomography, VAT area decreased by 30%. In all subjects, epicardial adipose thickness was reduced by 14% (both P < 0.0001) in tandem with reductions in ventricular interdependence. LV and right ventricular longitudinal strain improved following WL, but left atrial (LA) strain deteriorated, while LA volume and estimated LA pressures increased. In subgroup analysis, LV wall thickness and strain correlated more strongly with VAT than BMI at baseline, and reductions in LV mass following surgery were correlated with decreases in VAT, but not BMI.

Conclusions: In this observational study, weight loss following bariatric surgery was associated with epicardial fat reduction, reduced ventricular interaction, LV reverse remodeling, and improved longitudinal biventricular mechanics, but LA myopathy and hemodynamic congestion still progressed. Reduction in visceral fat was associated with favorable cardiac effects, suggesting this might be a key target of WL interventions.

Keywords: bariatric surgery; cardiac function; cardiac structure; heart failure; obesity.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Sorimachi is supported by a research fellowship from the Uehara Memorial Foundation, Japan. Dr Rider was supported by BHF Intermediate Clinical Fellowship FS/16/70/32157; and has received consulting fees from Amgen, Cytokinetics, Servier, and GlaxoSmithKline. Dr Borlaug was supported by R01 HL128526 and U01 HL 160226, both from the National Institutes of Health (NIH); has received research grants from National Institutes of Health/National Heart, Lung, and Blood Institute, AstraZeneca, Corvia, Medtronic, GlaxoSmithKline, Mesoblast, Novartis, and Tenax Therapeutics; and has received consulting fees from Actelion, Amgen, Aria, Axon Therapies, Boehringer Ingelheim, Edwards Lifesciences, Eli Lilly, Imbria, Janssen, Merck, Novo Nordisk, and VADovations. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1:
Figure 1:. Patient Identification.
Flow diagram outlining patient exclusions to qualify for inclusion to arrive at the final sample of 213 patients with repeat assessments prior to and following bariatric surgery. TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; LVEF, left ventricular ejection fraction; F/U, follow-up; HOCM, hypertrophic obstructive cardiomyopathy; AS, aortic valve stenosis.
Figure 2:
Figure 2:. Heatmap showing correlations between body compositions and cardiac structure/function.
Colors show strength and direction of correlation between measures of body fat with myocardial structure and function in the study cohort. †Available for n=52. BW, body weight; BMI, body mass index; VAT, visceral adipose tissue; SAT, subcutaneous adipose tissue; IVSd, interventricular septal dimension; PWd, posterior wall dimension; LV, left ventricular; RWT, relative wall thickness; EF, ejection fraction; GLS, global longitudinal strain; RV, right ventricular; FAC, fractional area change; FWLS, free wall longitudinal strain.
Figure 3:
Figure 3:. Effects of Weight Loss on Cardiac Structure and Function.
(A) Changes in body mass components. (B) Changes in LV mass were modestly correlated with changes in VAT-area. (C) Reduction in LVEF and eFS and improvements in LV GLS were observed. RV FAC did not change, but RV GLS and RV FWLS improved. Ventricular interaction assessed by LV eccentricity index and ideal-to-actual LV ratio was reduced following surgical weight loss. VAT, visceral adipose tissue; SAT, subcutaneous adipose tissue; BW, body weight; BMI, body mass index; EAT, epicardial adipose tissue; LV, left ventricular; EF, ejection fraction; eFS, endocardial fractional shortening; FAC, fractional area change; GLS, global longitudinal strain; RV, right ventricular; FWLS, free wall longitudinal strain. Eccentricity index and Ideal/actual radius were measured at end diastole. *p<0.05 between Exam 1 and Exam 2. †Available for n=52. Error bars indicate SEM in Figure 3A and 3C. Solid line represents regression line and dashed lines represent 95% confidence interval in Figure 3B
Figure 3:
Figure 3:. Effects of Weight Loss on Cardiac Structure and Function.
(A) Changes in body mass components. (B) Changes in LV mass were modestly correlated with changes in VAT-area. (C) Reduction in LVEF and eFS and improvements in LV GLS were observed. RV FAC did not change, but RV GLS and RV FWLS improved. Ventricular interaction assessed by LV eccentricity index and ideal-to-actual LV ratio was reduced following surgical weight loss. VAT, visceral adipose tissue; SAT, subcutaneous adipose tissue; BW, body weight; BMI, body mass index; EAT, epicardial adipose tissue; LV, left ventricular; EF, ejection fraction; eFS, endocardial fractional shortening; FAC, fractional area change; GLS, global longitudinal strain; RV, right ventricular; FWLS, free wall longitudinal strain. Eccentricity index and Ideal/actual radius were measured at end diastole. *p<0.05 between Exam 1 and Exam 2. †Available for n=52. Error bars indicate SEM in Figure 3A and 3C. Solid line represents regression line and dashed lines represent 95% confidence interval in Figure 3B
Figure 3:
Figure 3:. Effects of Weight Loss on Cardiac Structure and Function.
(A) Changes in body mass components. (B) Changes in LV mass were modestly correlated with changes in VAT-area. (C) Reduction in LVEF and eFS and improvements in LV GLS were observed. RV FAC did not change, but RV GLS and RV FWLS improved. Ventricular interaction assessed by LV eccentricity index and ideal-to-actual LV ratio was reduced following surgical weight loss. VAT, visceral adipose tissue; SAT, subcutaneous adipose tissue; BW, body weight; BMI, body mass index; EAT, epicardial adipose tissue; LV, left ventricular; EF, ejection fraction; eFS, endocardial fractional shortening; FAC, fractional area change; GLS, global longitudinal strain; RV, right ventricular; FWLS, free wall longitudinal strain. Eccentricity index and Ideal/actual radius were measured at end diastole. *p<0.05 between Exam 1 and Exam 2. †Available for n=52. Error bars indicate SEM in Figure 3A and 3C. Solid line represents regression line and dashed lines represent 95% confidence interval in Figure 3B
Central Illustration:
Central Illustration:
Cardiac dysfunction in Obesity and Effects of Surgical Weight Loss. Systemic inflammation, volume overload and derangement of myocardial metabolism caused by morbid obesity result in myocardial dysfunction. Surgical weight loss improved LV remodeling, biventricular function, and pericardial restraint. In contrast, elevation of E/e’ and LA myopathy progressed.
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