Safety and efficacy of single-balloon enteroscopy in management of gastrointestinal bleeding in patients with a left ventricular assist device

Abstract

Background and study aims Left ventricular assist devices (LVADs) are currently the standard of care in treatment of patients with end-stage heart failure waiting for heart transplant as well as destination therapy for non-transplant candidates. However, patients with LVADs are at increased risk of gastrointestinal bleeding due to the device’s unique effects on hemodynamics. A major source of gastrointestinal bleeding in these patients are gastrointestinal angioectasias located within the small bowel that can only be reached with deep enteroscopy. The goal of our study was to determine the safety and efficacy of single-balloon enteroscopy (SBE) in treating gastrointestinal bleeding in patients with LVADs. Patients and methods We present a retrospective case series performed on patients with LVADs who underwent SBE to treat episodes of gastrointestinal bleeding. All procedures were performed at Emory University Hospital by a single endoscopist. Patient demographics, diagnosis and treatment of gastrointestinal bleeding, episodes of re-bleeding, and procedure-related complications were examined. Results A total of 27 SBE procedures performed in 14 patients were reviewed. SBE was performed in an antegrade approach in 89 % (24/27) of cases. Deep intubation was achieved in all antegrade procedures, with the distal jejunum reached in 79 % (19/24) of cases. The diagnostic yield was 78 %. There were no reported complications associated with the procedures. Conclusions SBE is a safe and effective modality to manage gastrointestinal bleeding in patients with LVADs.

Utility and safety of balloon-assisted enteroscopy in patients with left ventricular assist devices: a retrospective multicenter study

“…The first and second-year survival benefits for advanced CHF patients on LVADs were demonstrated in the landmark REMATCH trial but also a 42 % incidence of gastrointestinal bleeding at 6 months of follow-up 9 . Other studies have reported incidence rates between 20 % to 30 % 3 10 . As noted in our results, the most common source of bleeding is small-bowel angioectasias/AVMs 4 11 12 13 14 .…”

“…But major AEs related to BAE have been previously reported, including pancreatitis, perforation, aspiration pneumonia, and death 23 24 . Others have reported no AEs associated with the procedure 5 6 10 . In our study, no major AEs were noted related to the enteroscopy procedure despite the majority of patients being classified as ASA class IV.…”

“…Multiple pathological mechanisms have been proposed to account for the increased incidence of gastrointestinal bleeding. Continuous impeller action and increased turbulence in the outflow and inflow cannula of the LVAD pump causes proteolysis of von Willebrand factor (vWF), thus impairing platelet mediated hemostasis 3 10 15 . Formation of AVMs may be due to the narrow pulse pressure generated by the LVAD, leading to decreased intraluminal pressure and dilation of the mucosal veins 16 .…”