Obesity is a common and potentially modifiable barrier to heart transplant candidacy in patients supported by a durable left ventricular assist device (LVAD). Approximately 15% of LVAD recipients carry a body mass index (BMI) of 35 kg/m2 or greater; the 2024 International Society for Heart and Lung Transplantation guideline considers weight loss to a BMI below 35 kg/m2 reasonable before listing, within an individualized assessment, and only 18.6% of these patients achieve a 10% weight reduction through supportive care alone. Two interventions can close this gap. Anti-obesity medications, principally glucagon-like peptide-1 receptor agonists (GLP-1 RAs), reduce BMI gradually without a procedural intervention; however, the largest LVAD series reports a BMI reduction from 38.3 to 36.2 kg/m2 at one year with 26% of patients who began above 35 kg/m2 falling below it, and efficacy depends on continued adherence and insurance coverage. In the FIGHT trial, liraglutide showed a non-significant, numerically unfavorable signal in recently hospitalized patients with advanced heart failure with reduced ejection fraction who were not on mechanical support. Metabolic bariatric surgery, most often laparoscopic sleeve gastrectomy, delivers a BMI reduction of 6 to 10 kg/m2 within 6 to 12 months and was associated with a threefold higher probability of subsequent transplantation in an observational Medicare cohort, at the cost of serious 30-day complications in 11.3% of LVAD recipients compared with 2.5% of non-LVAD bariatric patients. This narrative review compares mechanisms, LVAD-specific liabilities, and published outcomes of both strategies, including cardiovascular and arrhythmic outcomes, and reframes the choice as a trade-off between the speed of BMI reduction and the distribution of risk over time. We propose a hypothesis-generating selection framework, based on expert opinion, that considers excess BMI above threshold, expected time on device, bleeding profile, and gastrointestinal tolerance, and we define the evidence gaps that a prospective study should address.
