Gastrointestinal Angiodysplasia Resolution After Transcatheter Aortic Valve Implantation

Abstract

Importance: Heyde syndrome is the cooccurrence of aortic stenosis and gastrointestinal bleeding secondary to vascular lesions, including angiodysplasias. Several studies have demonstrated cessation of gastrointestinal bleeding after transcatheter aortic valve implantation (TAVI), but the etiology and effects on vascular lesions are largely unknown.

Objective: To examine the associations of TAVI with gastrointestinal vascular lesions and identify factors associated with recovery among patients with iron deficiency anemia and severe aortic stenosis.

Design, setting, and participants: In this prospective, single-center cohort study, patients with iron deficiency anemia on the TAVI waiting list from September 2020 to February 2022 were assessed by capsule endoscopy. Those with vascular lesions were reassessed 6 months after TAVI. Endoscopic images were anonymized and evaluated by 2 independent researchers. Data were analyzed from September 2022 to August 2024.

Exposure: TAVI.

Main outcomes and measures: The primary outcome was the mean difference in the number of vascular lesions before vs after TAVI.

Results: A total of 24 patients (mean [SD] age, 77.4 [7.1] years; 18 [75.0%] male) underwent capsule endoscopy, and vascular lesions were present in 18 patients (75.0%). TAVI was performed in 15 of 18 patients with vascular lesions, of whom 11 agreed to a second capsule endoscopy. The mean (SD) number of vascular lesions across the gastrointestinal tract decreased from 6.4 (5.6) lesions before TAVI to 2.0 (2.1) lesions 6 months after TAVI (P = .04). The number of vascular lesions decreased in 9 of 11 patients (81.8%), including 6 patients (54.5%) who no longer had typical angiodysplasias. Resolution of angiodysplasias was less frequent in patients who had multiple valvular heart disease before TAVI (0 of 3 patients) vs those without multiple valvular heart disease (6 of 8 patients [75.0%]) and in patients with significant paravalvular leakage after TAVI (2 of 5 patients [40.0%]) vs those without significant leakage (4 of 6 patients [66.7%]).

Conclusions and relevance: In this cohort study of 24 patients with iron deficiency anemia and severe aortic stenosis, angiodysplasias were present in 75.0% of patients. TAVI was associated with reduced size and number of angiodysplasias in these patients. These findings suggest that TAVI not only improves aortic stenosis but may also reduce gastrointestinal bleeding by resolving vascular lesions, offering a dual benefit for patients with Heyde syndrome.

Figure 1.. Participant Flowchart

TAVI indicates transcatheter aortic valve implantation.

Figure 2.. Differences in Vascular Lesions Before vs After Transcatheter Aortic Valve Implantation

T1 indicates before transcatheter aortic valve implantation; T2, 6 months after transcatheter aortic valve implantation. Boxes indicate IQR; horizontal lines, medians; whiskers, range; diamonds, outliers; and circles, individual patients.

Figure 3.. Differences in Laboratory Values Before vs After Transcatheter Aortic Valve Implantation

T1 indicates before transcatheter aortic valve implantation; T2, <72 hours after transcatheter aortic valve implantation; T3, 3 months after transcatheter aortic valve implantation; T4, 6 months after transcatheter aortic valve implantation; VEGF, vascular endothelial growth factor; VWF, von Willebrand factor; VWF:Ag, VWF antigen; VWF-HMWM, high–molecular weight multimers; VWF:RCoF, VWF ristocetin cofactor. Boxes indicate IQRs; horizontal lines, medians; whiskers, range; diamonds, outliers; dotted lines, reference range (A) or thresholds to diagnose acquired von Willebrand disease (C and D). The results of 1 patient are not depicted in B, as their levels far exceeded those of the other patients (30 341 pg/mL at T1, 23 213 pg/mL at T2, 21 503 pg/mL at T3, and 16 520 pg/mL at T4).