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Background Left ventricular assist devices (LVADs) have revolutionized management of end stage heart failure (ESHF). However, unexpectedly high rates of gastrointestinal bleeding (GIB) have been described, and etiologies 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 yr, 122 M/32F) with LVADs implanted over a 10 year period. Interventions None Main outcome measurements Overt or occult GIB prompting endoscopic evaluation ≥7 days after LVAD implant. Results Over a mean of 0.9 ± 0.1 yrs of follow-up, 29 patients (19%) developed 44 GIB episodes. Patients with GIB were older and anticoagulated before device implant (p ≤ 0.02 for each). GIB was overt (n=31) rather than occult (n=13), and most 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 highest diagnostic yield, peptic bleeding (n=14) and vascular malformations (n=8) dominated findings. Endoscopy was safe and well tolerated. Overall mortality was 35%, none directly from GIB. Limitations Retrospective design. Conclusions Rates of GIB with LVADs are higher than that seen in other patient populations, including those on anticoagulation and antiplatelet therapy. GIB episodes are mostly overt and predominantly from the upper GI tract. Endoscopy is safe in the LVAD population.