Evaluation of GI bleeding after implantation of left ventricular assist device

Abstract

Background: Left ventricular assist devices (LVADs) have revolutionized the management of end-stage heart failure (ESHF). However, unexpectedly high rates of GI bleeding (GIB) have been described, and etiology and outcome remain unclear.

Objective: To determine the prevalence, etiology, and outcome of GIB in LVAD recipients.

Design: Retrospective case series.

Setting: Tertiary care academic university hospital.

Patients: 154 ESHF patients (55.4 years, 122 men/32 women) with LVADs implanted over a 10-year period.

Main outcome measurements: Overt or occult GIB prompting endoscopic evaluation ≥ 7 days after LVAD implantation.

Results: Over a mean of 0.9 ± 0.1 years of follow-up, 29 patients (19%) experienced 44 GIB episodes. Patients with GIB were older and received anticoagulation therapy before devices were implanted (P ≤ .02 for each). GIB was overt (n = 31) rather than occult (n = 13), and most patients presented with melena (n = 22, 50%); hemodynamic instability was observed in 13.6%. Each bleeding episode required 2.1 ± 0.1 diagnostic or therapeutic procedures, and a source was localized in 71%. Upper endoscopy provided the highest diagnostic yield; peptic bleeding (n = 14) and vascular malformations (n = 8) dominated the findings. Endoscopy was safe and well tolerated. Overall mortality was 35%, none directly from GIB.

Limitation: Retrospective design.

Conclusions: Rates of GIB with LVADs are higher than that seen in other patient populations, including those receiving anticoagulation and antiplatelet therapy. GIB episodes are mostly overt and predominantly from the upper GI tract. Endoscopy is safe in the LVAD population.

Figure 1

Diagnostic yield of endoscopic and radiologic procedures performed for the evaluation of gastrointestinal bleeding in patients with LVADs. Upper endoscopy had the highest yield for a source of bleeding, significantly higher than that seen with colonoscopy or enteroscopy. The number of capsule endoscopy (5) and radiologic procedures (8) performed were limited. (*p<0.05 compared to colonoscopy and enteroscopy)