Obésité: ses conséquences sur le parcours de soin du cardiaque Laurent Sebbag, MD, PhD Hopital Louis Pradel BRON

Au Stade de l’insuffisance cardiaque, l’obésité est source de : Difficulté d’évaluation de la symptomatologie Difficulté de la stratification pronostique (VO2?) Difficulté d’appreciation des valeurs biologiques (BNP) Difficulté de détermination des posologies optimales Dégradation clinique par les comorbidités

Waring ME et al. Am J Med. Sep 2011; 124(9): 834–840 5-year mortality in relation to admission weight status*, among patients with diabetes hospitalized for heart failure * Underweight (18.5 kg/m2 < body mass index [BMI]), normal weight (18.5 kg/m2 ≤ BMI < 25 kg/m2), overweight (25 kg/m2 ≤ BMI < 30 kg/m2), Class I obesity (30 kg/m2 ≤ BMI < 35 kg/m2), Class II obesity (35 kg/m2 ≤ BMI < 40 kg/m2), and Class III obesity (40 kg/m2 ≤ BMI). Crude HRs (black) adjusted for study cohort. Multivariate-adjusted HRs (grey) adjusted for study cohort (1995 versus 2000), age (categorical), sex, DNR, GFR (continuous), length of stay (continuous), history of hypertension, history of COPD, history of PVD, history of PCI, history of CABG, and history of atrial fibrillation. Waring ME et al. Am J Med. Sep 2011; 124(9): 834–840

Dans le projet thérapeutique global que ce posent les enjeux Difficultés d’accès à la greffe cardiaque Complications post opératoires des chirurgies de greffe ou d’assistances circulatoire de longue durée

Obésité et Greffe cardiaque

Adult Heart Transplants Donor and Recipient Characteristics 1992-2000 (N = 37,146) 2001-2005 (N = 17,183) 2006-6/2012 (N = 22,318) p-value Recipient age (years) 54.0 (28.0 - 65.0) 54.0 (26.0 - 66.0) 54.0 (24.0 - 67.0) <0.0001 Donor age (years) 31.0 (15.0 - 54.0) 33.0 (16.0 - 55.0) 34.0 (17.0 - 56.0) Donor and recipient age difference (years) -19.0 (-44.0 - 7.0) -17.0 (-43.0 - 10.0) -16.0 (-43.0 - 12.0) Recipient weight (kg) 75.0 (51.0 - 102.0) 77.6 (53.0 - 106.6) 79.4 (53.1 - 110.0) Recipient height (cm) 173.0 (157.0 - 188.0) 174.0 (157.5 - 188.0) 175.0 (157.4 - 188.0) 0.0042 Recipient BMI 22.7 (19.5 - 31.7) 24.2 (19.6 - 33.1) 24.4 (19.6 - 34.3) Donor weight (kg) 75.0 (52.0 - 103.3)1 76.8 (55.0 - 108.8) 79.4 (56.7 - 113.0) Donor height (cm) 175.0 (155.0 - 188.0)1 175.3 (158.0 - 189.0) 175.0 (158.0 - 190.0) Donor BMI 24.2 (18.8 - 32.9)1 24.8 (19.5 - 34.4) 25.5 (19.9 - 36.4) Comparisons for categorical variables were made using the chi-square statistic. Multiple groups were compared using single p-value. Comparisons for continuous variables were made using Kruskal-Wallis test. A significant p-value means that at least one of the groups is different than the others but it doesn’t identify which group it is. Continuous factors are expressed as median (5th-95th percentiles) JHLT. 2013 Oct; 32(10): 951-964 2013 1 Based on 4/1994-2000 transplants.

Adult Heart Transplants Recipient BMI Distribution By Location (Transplants: January 2006 – June 2012) JHLT. 2013 Oct; 32(10): 951-964 2013

Adult Heart Transplants Recipient BMI Distribution By Diagnosis (Transplants: January 2006 – June 2012) JHLT. 2013 Oct; 32(10): 951-964 2013

Problème principal est celui de l’appariement morphologique d’un receveur obese avec un donneur qui ne le serait pas !!

Adult Heart Transplants Kaplan-Meier Survival by Era (Transplants: January 1982 – June 2011) All pair-wise comparisons were significant at p < 0.0001 except 2002-2005 vs. 2006-6/2011 (p = 0.9749) Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow-up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. The median survival is the estimated time point at which 50% of all of the recipients have died. Survival rates were compared using the log-rank test statistic. Adjustments for multiple comparisons were done using Scheffe’s method. JHLT. 2013 Oct; 32(10): 951-964 2013

Adult Heart Transplants Kaplan-Meier Survival by Donor/Recipient Weight Ratio (Transplants: January 2003 – June 2011) For recipients with PVR: 5+ wood units No pair-wise comparisons were significant at p < 0.05 Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow-up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. Survival rates were compared using the log-rank test statistic. Adjustments for multiple comparisons were done using Scheffe’s method. JHLT. 2013 Oct; 32(10): 951-964 2013

A DOMICILE EN SERVICE Le niveau de risque varie selon le degré d’urgence: plus le malade est instable moins la différence de poids est acceptable et plus il faudra surdimensionner le donneur EN USIC De Meester et al . J Heart Lung Transplant 2001; 20:1099

poids 75 74 87 88 91 85 97 50 55 76 72 84 Grp urgence Etat LY3XC A CIT sexe age poids taille Cardiopathie Situation du patient RAP Delai d'attente jours LY3XC   A M 47 75 175 Congénitale Tétralogie de Fallot +CIA opérée +RVP non cal 453 CIT 66 74 177 Ischémique Pose Jarvik le 18/11/2014 119 (09/2014) 18 SU1 163 Congénitale VU Retransplantation non fait 203 56 87 184 Valvulaire (RVM en 1991) 119 (01/2014) 805 LY3XM 49 183 Dilatée 177 (09/2012) 69 59 88 168 Ischémique (PACX4 en 1997) 184 (10/2011) 1071 53 91 Valvulaire (RVM en 2011) 60 (03/2013) 579 52 178 110 (08/2013) 1076 UR 34 85 170 187 (06/2014) 22 97 Ischémique (PAC X4 en2006) 287 (01/2014) 302 F 43 50 Rejet chronique Greffée cœur le 14/11/1992 En attente Cœur + Rein 298 O 35 174 Congénitale : atrésie pulmonaire, Blalock G, Fontan, Bicavo pulm 155 (05/2013) 497 sévère 55 165 Congénital:LTGV,large CIV(+/-VU) CIAR,RP,IT ATCD:BT droit,Gortex Gauche CI à l'assistance 1903 38 76 169 101 (10/2014) 15 63 72 176 Rythmique+Ischémique 189 (04/2014) 140 84 173 Pose Jarvik le 31/03/2014 196 (05/2012) 798

En dialyse péritonéale Pose assistance Droite post-transplantation LY3XM   O UR M 56 78 162 Ischémique 296 (09/2014) 64 57 100 178 Dilatée 258 (07/2013) 434 61 87 180 107 (03/2014) 662 171 148 (02/2014) 1617 52 92 172 En dialyse péritonéale 80 (04/2013) 2038 39 111 RAP=340 et 226 ap.dobu (07/2012) 1575 LY3XC B 38 97 88 (09/2014) 40 47 74 175 Pose assistance Droite post-transplantation 538 (04/2014) 160 AB CIT 82 168 Pose Thoratec le 18/11/2014 148 (11/2014) 11

Repartition des BMI receveurs cohorte 2004-2014 nb de greffes % greffes nb de DC < 20 (maigreur) 36 11% 10% (9) 20 - 25 (normal) 177 54% 53% (50) 25 - 30 (surpoids) 87 27% 31% (29) 30 - 40 (obésité) 26 8% 6% (6) > 40 (obésité morbide) 0%   Total 326 94

IMPACT BMI Receveur sur la Durée d’attente <18,5 18,5-25 >35 25-30 30-35

ADULT HEART TRANSPLANTS (2006-6/2011) Risk Factors For 1 Year Mortality with 95% Confidence Limits Donor BMI/Recipient BMI ratio p = 0.0029 Multivariable analysis was performed using a proportional hazards model censoring all patients at 1 year. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 10,473)

ADULT HEART TRANSPLANTS (2002-6/2007) Risk Factors For 5 Year Mortality with 95% Confidence Limits Recipient and Donor BMI Multivariable analysis was performed using a proportional hazards model censoring all patients at 5 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. Recipient BMI: p < 0.0001 Donor BMI: p = 0.012 JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 10,332)

ADULT HEART TRANSPLANTS (2002-6/2007) Risk Factors For 5 Year Mortality with 95% Confidence Limits Conditional on Survival to 1 Year Recipient BMI p = 0.048 Multivariable analysis was performed using a proportional hazards model censoring all patients at 5 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 8,873)

ADULT HEART TRANSPLANTS (1997-6/2002) Risk Factors For 10 Year Mortality with 95% Confidence Limits Recipient Weight p = 0.0137 Multivariable analysis was performed using a proportional hazards model censoring all patients at 10 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 11,531)

ADULT HEART TRANSPLANTS (1992-6/1997) Risk Factors For 15 Year Mortality with 95% Confidence Limits Recipient BMI p = 0.0002 Multivariable analysis was performed using a proportional hazards model censoring all patients at 15 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 11,055)

ADULT HEART TRANSPLANTS (2002-6/2007) Risk Factors for Developing Severe Renal Dysfunction within 5 Years Limited to Recipients without Severe Renal Dysfunction* Pre-Transplant Conditional on Survival to Transplant Discharge Recipient Weight p = 0.0061 Multivariable analysis was performed using a proportional hazards model censoring all patients at 5 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. *Severe renal dysfunction = creatinine > 2.5 mg/dl or dialysis JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 8,182)

ADULT HEART TRANSPLANTS (2002-6/2007) Risk Factors for Developing CAV within 5 Years Conditional on Survival to Transplant Discharge Recipient BMI p = 0.0026 Multivariable analysis was performed using a proportional hazards model censoring all patients at 5 Years. Continuous factors were fit using a restricted cubic spline. Analyses were limited to transplants having essentially complete information regarding risk factors. JHLT. 2013 Oct; 32(10): 951-964 2013 (N = 7,778)

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