Gastrointestinal angiodysplasia is associated with significant gastrointestinal bleeding in patients with continuous left ventricular assist devices

Abstract

Background and study aims: Patients with a continuous-flow left ventricular assist device (LVAD) have a 65 % incidence of bleeding events within the first year. The majority of gastrointestinal bleeding (GIB) is from gastrointestinal angiodyplasia (GIAD). The primary aim of the study was to determine whether GIAD was associated with a higher rate of significant bleeding, an increased number of bleeding events per year, and a higher rate of transfusion compared to non-GIAD sources. Patients and methods: This retrospective cohort study included 118 individuals who received a LVAD at a tertiary medical center from 2006 through 2014. Patients were subdivided into GIB and non-GIB for comparison of patient demographics, comorbid conditions, and laboratory data. GIB was further divided into sources of GIB, GIAD, obscure, or non-GIAD to establish severity of bleeding, rate of re-bleeding, and transfusion rate. Results: GIAD is associated with an increased number of bleeding events compared to non-GIAD sources of GIB (2.07 vs 1.23, P = 0.01) and a higher number of bleeding events per year (0.806 vs. 0.455 P = 0.001). GIAD compared to non-GIAD sources of GIB was associated with an increased incidence of major bleeding (100 % vs 60 %, P = 0.006) and increased rates of transfusion (8.8 vs 2.95 units, P = 0.0004). Cox Regression analysis between non-GIB and GIAD demonstrated increased risk with age (P = 0.001), history of chronic kidney disease (P = 0.005), and length of stay after LVAD implantation of more than 45 days (P = 0.04). History of hypertension (P = 0.045), diabetes mellitus (P = 0.016), and male gender was associated with decreased risk (P = 0.04). Conclusion: Patients with a continuous-flow LVAD who develop a GIB secondary to GIAD have a higher rate of major bleeding, multiple bleeding events, and require more transfusions to achieve stabilization compared to patients who do not have GIAD.

A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds

“…of pts controlsNo. of pts with GIADStudy populationComparison groupOutcomeEffect HR (95%-CI)/ t testHolleran et al Ireland, 2013 [29]CC9566Small bowel GIAD at SBCE/51% anemia, 23% overt bleeding, 15% OGIB, 11% otherNo GI bleeding/determined by two negative FOBT for colorectal cancer screening programHypertension2.8 (1.5–5.4)Ischemic heart disease4.3 (1.9–9.8)Arrhythmias4.4 (1.7–11.2)Valvular heart disease18.8 (2.4–149.6)Congestive cardiac failure4.5 (1.2–17.9)CKD4.5 (1.9–10.5)Previous VTE6.4 (1.3–31.3)Anticoagulant use a 2.7 (1.4–5.1)Warfarin a 5.5 (1.1–27.5)Proton pump inhibitor a 5.4 (2.7–10.7)Cochrane et al USA, 2016 [33]CC5614LVAD and GIAD diagnosed with EGD or colonoscopyLVAD without GI bleedingAge1.3 (1.1–1.6)CKD21.0 (2.5–181)Length of stay after LVAD5.1 (1.1–23.7)Sex: male0.1 (0.01–0.9)Diabetes mellitus0.9 (0.01–0.6)Hypertension0.2 (0.1–0.97)Duchini et al USA, 1998 [37]RC1359SS/CREST and GIAD bleeding/endoscopy or radiology NSSS/CREST without clinical signs of GI bleeding6.3% have GI bleeding due to GIADNAKim et al Korea, 2016 [41]RC35…”

“…In studies focused one specific patient category, the following conditions are risk factors for angiodysplasias: LVADs, mitral valve regurgitation [34] and systemic sclerosis and calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia (CREST) syndrome (6.3% of GI bleeding due to AD) [35, 38]. Hypertension was identified as a risk factor for small bowel disease (OR 2.8, 95% CI 1.5–5.4) [29], although its presence may confer protection against bleeding in patients with LVADs (OR 0.2, 95% CI 0.1–0.97) [33].…”

Decreased Platelet Specific Receptor Expression of P-Selectin and GPIIb/IIIa Predict Future Non-Surgical Bleeding in Patients after Left Ventricular Assist Device Implantation

“…In the past, various hemocompatibility parameters (e.g., vWF diagnostic, generation of reactive oxygen species, platelet aggregation) have been investigated to identify a reliable biomarker for bleeding risk stratification in LVAD patients [ 4 , 8 , 17 , 22 ]. A combined examination for angiodysplasia and aVWS seemed to be able to explain the occurrence of NSB [ 23 , 24 , 25 , 26 , 27 ]. Today, it is already known that the majority of LVAD patients develop an aVWS by the loss of high molecular multimers; however, the analyzed vWF profiles are not suitable to discriminate between patients with and without bleeding complications [ 6 , 8 , 24 ].…”

Early massive gastrointestinal bleeding as a complication of left ventricular assist device implantation

“…8 High shear forces produced by the continuous blood flow result in increased consumption of the von Willebrand factor, leading to a hemostatic disorder similar to the hereditary von Willebrand disease. 9 The consequent impaired hemostatic cascade and platelet aggregation further contribute to the bleeding risk. This condition, called the acquired von Willebrand syndrome, has been observed in patients with various cardiovascular diseases, such as aortic stenosis, hypertrophic obstructive cardiomyopathy, as well as various forms of mechanical circulatory support like extracorporeal membranous oxygenation (ECMO) and LVAD.…”