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

Ahsan, Irfan; Faraz, Aniqa; Mehmood, Asif; Ullah, Waqas; Ghani, Ali

doi:10.7759/cureus.6341

Cited by 8 publications

(21 citation statements)

References 46 publications

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“…This large observational study analyzes GIB in continuous-flow LVAD patients, investigating clinical patterns that can inform the clinical evaluation and management of these complex patients. Our findings confirm a high rate of GIB, especially in destination patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients who present with occult bleeding ( 15 – 18 ). Overt bleeding was more frequent and may originate from anywhere in the GI tract.…”

Section: Discussionsupporting

confidence: 74%

A multi-center study of left ventricular assist device (LVAD)-related gastrointestinal bleeding

Dailey

Nguyen

Kohli

et al. 2022

Clin Transl Gastroenterol

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INTRODUCTION: Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients. METHODS: We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB. RESULTS: We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05–5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29–12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization. DISCUSSION: Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.

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Section: Discussionsupporting

confidence: 74%

A multi-center study of left ventricular assist device (LVAD)-related gastrointestinal bleeding

Dailey

Nguyen

Kohli

et al. 2022

Clin Transl Gastroenterol

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“…Further longitudinal studies possibly using artificial intelligence algorithms are needed for better risk stratification. This review summarizes the most recent literature and differs from existing reviews and systematic reviews in that it is focused on the overall management with a suggested algorithm which includes pump speed adjustments 81,82 …”

Section: Discussionmentioning

confidence: 99%

“…This review summarizes the most recent literature and differs from existing reviews and systematic reviews in that it is focused on the overall management with a suggested algorithm which includes pump speed adjustments. 81,82 To date, a definitive strategy to manage GIB has not been identified, medical therapy targeting different pathophysiologic mechanisms of these lesions has been evaluated as primary and secondary preventative therapy for GIB in LVAD patients and needs further investigation. Based on the present literature review, we propose an algorithm for management of GIB in the acute and chronic settings.…”

Section: Discussionmentioning

confidence: 99%

Gastrointestinal bleeding in patients with continuous‐flow left ventricular assist devices: A comprehensive review

Rio‐Pertuz

Nair

2022

Artificial Organs

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Background Gastrointestinal bleeding is a major cause of morbidity that plagues the quality of life of patients supported on contemporary continuous‐flow left ventricular assist devices (CF‐LVADs). Despite benefits in survival and the nearly 50% reduction in complications provided by CF‐LVADs, bleeding remains one of the most frequent adverse events with CF‐LVAD implants. The CF‐LVADs cause an increased risk of bleeding mainly due to the activation of the coagulation cascade. Methods A literature search was done using PubMed and Google Scholar from Inception to February 2022. Qualitative analyses of the articles retrieved were used to construct this review. This review attempts to provide a comprehensive summary of the epidemiology, pathophysiology, risk stratification, and management of gastrointestinal bleeding as a complication of CF‐LVAD as well as propose an algorithm for diagnosis and treatment. Results Bleeding can occur at different sites in the gastrointestinal tract, the most common underlying pathology being arteriovenous malformations located in the upper gastrointestinal tract The increased prevalence of gastrointestinal (GI) bleeding in CF‐LVAD patients has been attributed to the physiology of the LVAD itself, the use of anticoagulants, as well as patient comorbidities. Management involves pharmacologic and nonpharmacologic strategies. Conclusions CF‐LVAD‐supported patients have a significant risk of GI bleeding that is mainly caused by arteriovenous malformations located in the upper GI tract. The increased prevalence of GI bleeding in CF‐LVAD patients is attributed to several etiologies that include factors attributed to the device itself and extrinsic factors such as the use of anticoagulation.

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“…In cases where the source of bleeding cannot be identified, the following measures have been reported to be used; capsule endoscopy, balloon enter-oscopy, tagged red cell scan and angiogram (mesenteric). Besides the preliminary management techniques outlined earlier, other therapeutic options employed in the management of GIB in these patients include electrocoagulation, laser photocoagulation, injection of hemostatic solutions, endoscopic ligation, use of argon plasma, clipping, and transcatheter embolization [53][54][55]. In severe cases with poor hemodynamics, surgical approach may be utilized as a diagnostic and therapeutic measure.…”

Section: Discussionmentioning

confidence: 99%

“…The use of direct thrombin and factor Xa inhibitors was not mentioned in any of the studies. Adequate blood pressure control and post-operative monitoring is advised to attain better outcomes [47][48][49][50][51][52][53][54][55]. Few studies have explored the use of genotype-guided warfarin therapy in these patients with most reporting promising outcomes with its use [56][57][58].…”

Section: Discussionmentioning

confidence: 99%

Gastrointestinal Bleeding as a Complication in Continuous Flow Ventricular Assist Devices: A Systematic Review With Meta-Analysis

et al. 2020

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Background The use of ventricular assist devices (VADs) has become predominant in this era of medicine. It is commonly used as a bridge to transplant, recovery and as a destination therapy for patients with severe heart failure, who are not responsive to maximum optimal management or ineligible for transplant. However, several complications are known to occur with the use of these devices. In this research, we will compare gastrointestinal bleeding in patients who used centrifugal flow versus axial flow VADs. We hope that the result of this meta-analysis and the review presented provide adequate information to future researchers, physicians and other healthcare professionals who are interested in this topic. Methods Published articles evaluated for inclusion were obtained from MEDLINE (PubMed), Cochrane, EBSCO, clinicaltrials.gov, and international clinical trials registry. This research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Procured articles were reviewed by two independent reviewers. Only randomized control trials and observational studies were used. Quality assessment was done with Cochrane Collaboration’s tool (RoB.2 with visualization through robviz) and Newcastle-Ottawa Scale (NOS). Data analysis was carried out with the use of R data analysis tool (version 4.0.0; release date: April 24th, 2020). Results At the end of this meta-analysis, the occurrence of gastrointestinal bleeding was not significantly different between both groups; with odds ratio (OR): 0.81; 95% confidence interval (CI): 0.65 - 1.00; P value = 0.05. Between-study variance (Tau-squared) was zero (0), standard error (SE) = 0.06. The degree of heterogeneity measured with I-squared statistic was 0% (minimal). Egger’s regression test was not statistically significant, P = 0.93. Symmetry of distribution was observed on the funnel plot. Trim and fill analysis showed no missing studies on the left; SE = 1.68. Conclusions The result obtained from this research indicates that the occurrence of gastrointestinal bleeding is not significantly different in both groups of patients, irrespective of the type of continuous flow VAD used. Although, the study sample used in this meta-analysis was limited.

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

Cited by 8 publications

References 46 publications

A multi-center study of left ventricular assist device (LVAD)-related gastrointestinal bleeding

A multi-center study of left ventricular assist device (LVAD)-related gastrointestinal bleeding

Gastrointestinal bleeding in patients with continuous‐flow left ventricular assist devices: A comprehensive review

Gastrointestinal Bleeding as a Complication in Continuous Flow Ventricular Assist Devices: A Systematic Review With Meta-Analysis

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