HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nicholas C. Cavarocchi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cavarocchi, N. C. Search for Related Content PubMed PubMed Citation Articles by Cavarocchi, N. C. Related Collections Cardiac - other Related Article

---

Original Articles: Adult Cardiac

Invited Commentary

Cardiac Transplantation, Penn State Milton S. Hershey Medical Center, Penn State Hershey Heart & Vascular Institute, 500 University Dr H165, PO Box 850, Hershey, PA 17033-0850

(Email: ncavarocchi{at}hmc.psu.edu).

Major public health consequences have evolved from the obesity epidemic in the United States and worldwide. It has been estimated that approximately 30% of the adult population in the United States is classified as obese, defined as a body mass index (BMI) > 30 kg/m². Obesity is an independent risk factor for cardiovascular disease (CVD) and is related to a constellation of comorbidities, such as hypertension (HTN), dyslipidemia, type II diabetes mellitus (DM), inflammation, thrombosis, renal dysfunction, and the insulin resistant syndrome [1–4]. Statistically, there is a significant increase of younger obese men and women who die from CVD when compared with people who have a normal BMI. In fact, for every 1 kg/m² increase in BMI, there is a 4% increase in the percentage of myocardial infarct, a 3% increase in CVA, a 6% increase in HTN, an 8% increase in venous thrombotic emboli, and a 5% increase in atrial fibrillation [5].

Older, surgical literature reported increased BMI as a risk factor for new onset atrial fibrillation, wound infections, increased intensive care (ICU) unit days and 30-day mortality [6–8]. However, the association between obesity and increased morbidity and mortality after coronary artery bypass grafting (CABG) remains mixed in recent articles. Rockx and colleagues [9] and Villancencio and colleagues [10] reported that increased BMI was not a predictor for major perioperative complications, except for increased ICU days. In fact, lower BMI was a greater risk factor for increased risk of perioperative complications than obesity.

The majority of published articles report obesity (BMI 30) as a homogeneous group of patients with fixed risk factors, which is not a statistical reality. This article [11] reviewed a subset of patients with extreme obesity (BMI 50) to assess the effect of this BMI subset on surgical morbidity and mortality after open heart surgery (OHS). Sun and colleagues [11] reported a series of 57 extremely obese patients (BMI 50) with a mean age of 58 years; mean BMI 55; 63% women; 52% African American; and a significant incidence of HTN, DM, and short height. Elective CABG was done in 72% of the patients while the remainder were nonelective. Approximately 50% of all CABG was done off-pump. Using a multi-variant analysis, extreme obesity did not emerge as a significant risk factor for operative mortality and other adverse outcomes after elective surgery. Extreme obesity was associated with increased mortality and as a risk factor for longer ICU days in overall surgery. In the subset analysis, the mortality of patients with extreme obesity was also not significantly different from normal BMI patients undergoing elective CABG and isolated coronary bypass surgery. There were five mortalities (all women); only two of which were related to coronary artery disease, and the other three were valvular heart disease.

Improvements in preoperative evaluation, intraoperative technique, and postoperative care can optimize the results with this high risk subset of patients with cardiovascular disease. Extremely obese patients can be offered elective CABG with a safe and acceptable risk profile when compared with patients who had normal BMIs. Obese patients risk profiles for morbidity and mortality will continue to evolve as surgeons collect, analyze, and report their data. The authors need to be commended on the formable surgical challenge of performing cardiac surgery on these extremely obese patients and having excellent results. Extremely obese patients remain a very high-risk group as defined by their 1-year mortality of 82.5% compared with all other levels of BMI.

	References

Top References

 

1. Lamon-Fava S, Wilson PWF, Schaefer EJ. Impact of body mass index on coronary heart disease risk factors in men and women: the Framingham Offspring Study Arterioscler Thromb Vasc Biol 1996;16:1509-1515.[Abstract/Free Full Text]
2. Krauss RM, Winston M, Fletcher BJ, et al. Obesity: impact on cardiovascular disease Circulation 1998;98:1472-1476.[Free Full Text]
3. Visscher TL, Seidell JC. The public health impact of obesity Annu Rev Public Health 2001;22:355-375.[Medline]
4. Eckel RH, Barouch WW, Ershow AG. Report of the National Heart, Lung, and Blood Institute-National Institute of Diabetes and Digestive and Kidney Diseases Working Group on the pathophysiology of obesity-associated cardiovascular disease Circulation 2002;105:2923-2928.[Free Full Text]
5. Murphy NF, MacIntyre K, Stewart S, Hart CL, Hole D, McMurray JJV. Long-term cardiovascular consequences of obesity; 20 year follow-up of more than 1500 middle aged men and women (The Renfrew-Paisley Study) Eur Heart J 2006;27:96-106.[Abstract/Free Full Text]
6. Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah AS, Habib RH. Obesity and risk of new-onset atrial fibrillation after cardiac surgery. Circulation 2885;112:3247–55.
7. Harrington G, Russo P, Spelman D, et al. Surgical-site infection rates and risk factor analysis in coronary artery bypass graft surgery Infect Control Hosp Epidemiol 2004;25:472-476.[Medline]
8. Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery Ann Thorac Surg 2004;77:676-683.[Abstract/Free Full Text]
9. Rockx MA, Fox SA, Stitt LW, et al. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? Can J Surg 2004;47:34-38.[Medline]
10. Villancencio MA, Sundt TM, Doly RC, et al. Cardiac surgery in patients with BMI of 50 or greater Ann Thorac Surg 2007;83:1403-1411.[Abstract/Free Full Text]
11. Sun X, Hill PC, Bafi AS, et al. Is cardiac surgery safe in extremely obese patients (body mass index 50 or greater)? Ann Thorac Surg 2009;87:540-547.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nicholas C. Cavarocchi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cavarocchi, N. C. Search for Related Content PubMed PubMed Citation Articles by Cavarocchi, N. C. Related Collections Cardiac - other Related Article