Clinical Approach to Manage Gastrointestinal Bleeding with a Left Ventricular Assist Device (LVAD)

Abstract

Left ventricular assist devices (LVADs) are an exceedingly important form of mechanical support for patients with end-stage heart failure. LVADs can be utilized both as a bridge to cardiac transplant and also as a definitive treatment. However, a few complications are associated with LVAD placement, the most common and cumbersome of which is gastrointestinal (GI) bleeding with an incidence of about 30%. These bleeding events often require transfusion therapy, but they are rarely fatal. The etiologies of GI bleeding following LVAD are multifactorial and include unstable hemodynamics, an acquired von Willebrand factor (vWf) deficiency, impaired platelet aggregation, and activation of fibrinolytic systems. The treatment of choice in LVAD implantation-associated GI bleeding is endoscopy, which plays a vital role in both its diagnosis and management. Even so, its effectiveness in controlling post-LVAD implantation GI bleeding is still poorly ascertained. In this article, we will review the use of medication and alterations in the LVAD setting to prevent the occurrence of GI bleeding, as well as the findings of previously reported literature on LVAD implantation-associated GI bleeding.

Keywords: end-stage heart failure; gastrointestinal bleeding; left ventricular assist device (lvad).

Figure 1. Algorithm on the pathophysiology of gastrointestinal bleeding

AVM: arteriovenous malformation; CF-LVAD: continuous-flow left ventricular assist device; GI: gastrointestinal; HMW: high-molecular-weight; vWD: von Willebrand disease; vWF: Von Willebrand factor

Figure 2. Flowsheet outlining the management approach to GI bleeding in patients with LVAD placements

CBC: complete blood count; GI: gastrointestinal; INR: international normalized ratio; LVAD: left ventricular assist devices; RBC: red blood cells