Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients

Abstract

Continuous-flow left ventricular assist devices (CF-LVADs) have significantly improved outcomes for patients with end-stage heart failure when used as a bridge to cardiac transplantation or, more recently, as destination therapy. However, its implantations carries a risk of complications including infection, device malfunction, arrhythmias, right ventricular failure, thromboembolic disease, postoperative and nonsurgical bleeding. A significant number of left ventricular assist devices (LVAD) recipients may experience recurrent gastrointestinal hemorrhage, mainly due to combination of antiplatelet and vitamin K antagonist therapy, activation of fibrinolytic pathway, acquired von Willebrand factor deficiency, and tendency to develop small intestinal angiodysplasias due to increased rotary speed of the pump. Gastrointestinal bleeding in LVAD patients remains a source of increased morbidity including the need for blood transfusions, extended hospital stays, multiple readmissions, and overall mortality. Management of gastrointestinal bleeding in LVAD patients involves multidisciplinary approach in stabilizing the patients, addressing risk factors and performing structured endoluminal evaluation with focus on upper gastrointestinal tract including jejunum to find and eradicate culprit lesion. Medical and procedural intervention is largely successful and universal bleeding cessation occurs in transplanted patients.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

“…It is cleaved by ADAMTS-13, glycosylated and cleared from the bloodstream with a half-life of 12-20 h. 25 The mechanical forces of aortic stenosis, left ventricular assist device, and extracorporeal membrane oxygenation can easily shear and deform the high molecular weight multimers into smaller fragments, which impairs thrombosis and interferes with platelet aggregation. 26,27 von Willebrand factor fragmentation may, by itself, be pro-angiogenic and potentially involved in GI hemorrhage in these severe settings. 26,28 Cross-sectional imaging Cross-sectional imaging techniques for evaluation of the small bowel include helical computed tomography enterography/enteroclysis (CTE), helical CT angiography, and magnetic resonance enterography/enteroclysis (MRE).…”

“…26,27 von Willebrand factor fragmentation may, by itself, be pro-angiogenic and potentially involved in GI hemorrhage in these severe settings. 26,28 Cross-sectional imaging Cross-sectional imaging techniques for evaluation of the small bowel include helical computed tomography enterography/enteroclysis (CTE), helical CT angiography, and magnetic resonance enterography/enteroclysis (MRE). 5 In an emergency, dynamic or enhanced helical CT without enterography/enteroclysis provides important information regarding mass lesions such as tumors, inflammation, and vascular diseases, including arteriovenous malformation (AVM, Fig.…”

Gastrointestinal Hemorrhage in Left Ventricular Assist Device Patients: Red Scare or Pressure from the Right?

“…Previous studies have suggested that the lowest chance of bleeding occurred in blood type A patients [12] and the highest in patients with history of GI hemorrhage prior to LVAD placement [11]. Furthermore, male gender and older age are recognizable risk factors [5]. There also seems to exist a possible correlation with GI hemorrhage in patients with easily observed nasal hypervascularity following LVAD implantation [13].…”

“…Historically, up to 60% of LVAD recipients may develop gastrointestinal (GI) hemorrhage [5]-an important issue given increased prevalence of implantation worldwide. In fact, it is the most common adverse event in patients with post-device implantation [3] and typically resolves after a heart transplant [5,6].…”

“…In fact, it is the most common adverse event in patients with post-device implantation [3] and typically resolves after a heart transplant [5,6]. Clinical effects of bleeding may vary, ranging from continual anemia in some patients to overt hemorrhage with hemodynamic compromise in others.…”