Skip to main content
SpringerLink
Log in

Gastrointestinal Bleeding During the Index Hospitalization for Mechanical Circulatory Support Devices Implantation, a Nationwide Perspective

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Gastrointestinal bleeding (GIB) is a common adverse event after mechanical circulatory support device implantation. However, the majority of the reported data were obtained from small single-center studies. Our aim was to study the prevalence and predictors of GIB during the index hospitalization of mechanical circulatory support devices implantation using a nationwide database.

Methods

Nationwide inpatient sample (2009–2011) was used to perform a retrospective cross-sectional study. Adult patients with discharge diagnosis codes of congestive heart failure and procedure codes of left-ventricular assist device (LVAD) or intra-aortic balloon pump (IABP) implantation or orthotopic heart transplant (OHT, reference group) were identified. Our outcome was GIB during the index hospitalization when the device was implanted. Predictors that achieved statistical significance on the univariate analysis were included in a multivariable logistic-regression analysis.

Results

A total of 87,462 patients were included, 87 % of the patients received an IABP, 6 % received LVAD, and 5 % underwent OHT. Prevalence of GIB was 8, 5, and 3 % among those who had LVAD, IABP implantation, and OHT recipients, respectively (p < 0.001). Patients who underwent LVAD implantation had twofold increase in the prevalence of GIB (OR 2.1, 1.7–2.5, p < 0.001) when using IABP or OHT groups as a reference. This increase in the prevalence was not demonstrated among IABP recipients on a multivariate level.

Conclusion

Prevalence of GIB was higher among LVAD compared to OHT and IABP recipients and could occur as early as the index admission of the device implantation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Kirklin JK, Naftel DC, Pagani FD, et al. Sixth INTERMACS annual report: a 10,000-patient database. J Heart Lung Transplant. 2014;33:555–564.

    Article  PubMed  Google Scholar 

  2. McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, Allen LA. Clinical outcomes after continuous-flow left ventricular assist device: a systematic review. Circ Heart Fail. 2014;7:1003–1013.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Harvey L, Holley CT, John R. Gastrointestinal bleed after left ventricular assist device implantation: incidence, management, and prevention. Ann Cardiothorac Surg. 2014;3:475–479.

    PubMed  PubMed Central  Google Scholar 

  4. Jabbar HR, Abbas A, Ahmed M, et al. The incidence, predictors and outcomes of gastrointestinal bleeding in patients with left ventricular assist device (LVAD). Dig Dis Sci. 2015;60:3697–3706.

    Article  PubMed  Google Scholar 

  5. Draper KV, Huang RJ, Gerson LB. GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis. Gastrointest Endosc. 2014;80:435.e431–446.e431.

    Article  Google Scholar 

  6. French JB, Pamboukian SV, George JF, et al. Gastrointestinal bleeding in patients with ventricular assist devices is highest immediately after implantation. ASAIO J. 2013;59:480–485.

    Article  PubMed  Google Scholar 

  7. Geisen U, Heilmann C, Beyersdorf F, et al. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease. Eur J Cardiothorac Surgery. 2008;33:679–684.

    Article  Google Scholar 

  8. Letsou GV, Shah N, Gregoric ID, Myers TJ, Delgado R, Frazier OH. Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device. J Heart Lung Transplant. 2005;24:105–109.

    Article  PubMed  Google Scholar 

  9. Eckman PM, John R. Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation. 2012;125:3038–3047.

    Article  PubMed  Google Scholar 

  10. Kantrowitz A. Experimental augmentation of coronary flow by retardation of the arterial pressure pulse. Surgery. 1953;34:678–687.

    CAS  PubMed  Google Scholar 

  11. (HCUP) HCaUP. Nationwide Inpatient Sample. USA: Healthcare Cost and Utilization Project (HCUP). http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed January 12, 2015.

  12. Mulloy DP, Bhamidipati CM, Stone ML, Ailawadi G, Kron IL, Kern JA. Orthotopic heart transplant versus left ventricular assist device: a national comparison of cost and survival. J Thorac Cardiovasc Surg. 2013;145:566–573 (discussion 564–573).

  13. Strate LL, Ayanian JZ, Kotler G, Syngal S. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol. 2008;6:1004–1010.

  14. Wysocki JD, Srivastav S, Winstead NS. A nationwide analysis of risk factors for mortality and time to endoscopy in upper gastrointestinal haemorrhage. Aliment Pharmacol Ther. 2012;36:30–36.

    Article  CAS  PubMed  Google Scholar 

  15. Navaneethan U, Njei B, Venkatesh PG, Sanaka MR. Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study. Gastrointest Endosc. 2014;79:297.e212–306.e212.

    Google Scholar 

  16. Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc. 2015;81:882–888.

  17. Khera S, Kolte D, Aronow WS, et al. Trends in acute kidney injury and outcomes after early percutaneous coronary intervention in patients ≥75 years of age with acute myocardial infarction. Am J Cardiol. 2013;112:1279–1286.

    Article  PubMed  Google Scholar 

  18. Lenihan CR, Montez-Rath ME, Mora Mangano CT, Chertow GM, Winkelmayer WC. Trends in acute kidney injury, associated use of dialysis, and mortality after cardiac surgery, 1999 to 2008. Ann Thorac Surg. 2013;95:20–28.

    Article  PubMed  Google Scholar 

  19. Waikar SS, Wald R, Chertow GM, et al. Validity of international classification of diseases, ninth revision, clinical modification codes for acute renal failure. J Am Soc Nephrol. 2006;17:1688–1694.

    Article  PubMed  Google Scholar 

  20. Taefi A, Cho WK, Nouraie M. Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades. Dig Dis Sci. 2013;58:2940–2948.

    Article  PubMed  Google Scholar 

  21. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 international society for heart and lung transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32:157–187.

    Article  PubMed  Google Scholar 

  22. Islam S, Cevik C, Madonna R, Frandah W, Islam E, Nugent K. Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series. Clin Cardiol. 2013;36:190–200.

    Article  PubMed  Google Scholar 

  23. Kushnir VM, Sharma S, Ewald GA, et al. Evaluation of GI bleeding after implantation of left ventricular assist device. Gastrointest Endosc. 2012;75:973–979.

    Article  PubMed  Google Scholar 

  24. Aggarwal A, Pant R, Kumar S, et al. Incidence and management of gastrointestinal bleeding with continuous flow assist devices. Ann Thorac Surg. 2012;93:1534–1540.

    Article  PubMed  Google Scholar 

  25. Slaughter MS. Hematologic effects of continuous flow left ventricular assist devices. J Cardiovasc Transl Res. 2010;3:618–624.

    Article  PubMed  Google Scholar 

Download references

Authors’ Contributions

Ali Abbas contributed to study concept and design; acquisition of data; statistical analysis; interpretation of the results; drafting of the manuscript; critical revision of the manuscript for important intellectual content. Ahmed Mahmoud contributed to study design, interpretation of the results; drafting of the manuscript and critical revision of the manuscript for important intellectual content. Mustafa Ahmed contributed to interpretation of the results; critical revision of the manuscript. Juan Aranda Jr. contributed to interpretation of results and critical revision of the manuscript. Charles T. Klodell Jr. contributed to interpretation of results and critical revision of the manuscript. Peter V. Draganov contributed to study concept and design; interpretation of the results; drafting of the manuscript; critical revision of the manuscript, and supervision of research activity.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Florida, PO Box 100277, Gainesville, FL, 32610, USA

    Ali Abbas & Ahmed Mahmoud

  2. Division of Cardiovascular Medicine, University of Florida, PO Box 100277, Gainesville, FL, 32610, USA

    Mustafa Ahmed & Juan Aranda Jr.

  3. Division of Thoracic and Cardiovascular Surgery, University of Florida, PO Box 100129, Gainesville, FL, 32610, USA

    Charles T. Klodell Jr.

  4. Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, 1600 SW Archer Rd, Box 100214, Gainesville, FL, 32610, USA

    Peter V. Draganov

Authors
  1. Ali Abbas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed Mahmoud
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mustafa Ahmed
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Juan Aranda Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Charles T. Klodell Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Peter V. Draganov
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter V. Draganov.

Ethics declarations

Conflict of interest

All authors have no potential conflicts (financial, professional, or personal) that are relevant to this manuscript. The study was conducted, and the manuscript was written and reviewed solely by the authors.

Appendices

Appendix 1: Identification of Gastrointestinal Bleeding

We used previously reported criteria to identify the spectrum of GIB from ICD9 in the NIS database [13–15]. GIB was identified by the presence of a specific code of cause with hemorrhage (example: duodenal ulcer with hemorrhage), or code of potential GIB cause and code of nonspecific GIB (duodenal ulcer + hematemesis or blood in stool codes), or code of GIB cause and code acute hemorrhagic anemia, or code of hematemesis or blood in stool codes (with no specific GI source), were classified as GIB not otherwise specified (NOS).

Based on the ICD9 codes, the final classification of GIB source and causes was as follows, upper GIB including: esophageal variceal bleed, non-variceal esophageal bleed, such as, esophagitis, ulcer, and Mallory–Weiss syndrome (MW), gastro-duodenal-jejunum pathology including ulcer, or inflammation, upper GI AVM and upper GIB NOS. Lower GIB including: AVM, diverticulosis, hemorrhoids or anal fissure, neoplastic lesions including polyps, or cancer, colitis, colon ulcer, ischemic colitis and lower GIB NOS. And GIB NOS if no code for potential source was found. Groups could overlap with the presence of more than one source.

Other Predictors of GIB Definitions

We identified acute complications that might have occurred during hospitalization, like AKI. For that purpose, we implemented previously used and validated algorithm [17, 18]. AKI was defined as the presence of specific ICD9 codes. AKI required dialysis (AKI/HD) was identified by the presence of AKI codes with hemodialysis codes, in the absence of end-stage renal disease (ESRD) codes. Presence of dialysis code without AKI codes and/or presence of ESRD specific codes identified ESRD. Patients with chronic kidney disease (CKD) codes were identified. Those with ESRD are mutually exclusive with the other groups of patients. However, patients with CKD can have AKI or AKI-HD [17–19].

We identified the occurrence of sepsis using a previously reported combination of ICD9 codes [17, 18]. Additionally, the occurrence of DIC, DVT, and pulmonary embolism were identified. The need for intubation—mechanical ventilation, and enteral or parenteral feeding were identified and included in the analysis as they can reflect the overall clinical severity. Liver disease was classified to mild (without complication of portal hypertension) and moderate to severe (with portal hypertension complications). Full list of the ICD9 codes that were used in this study is provided in the Appendix 2.

Appendix 2

See Tables 4, 5, 6 and 7.

Table 4 Descriptive summary of the identified variables in the included population (all the comparisons across procedure groups yielded p < 0.001, p values were estimated from t test for age, and from Chi-square or Fisher exact, when appropriate, for categorical variables)
Full size table
Table 5 Predictors of GIB among the included population with reference OHT
Full size table
Table 6 Predictors of GIB, after excluding OHT population and using IABP as a reference
Full size table
Table 7 ICD9 codes used in the study
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Abbas, A., Mahmoud, A., Ahmed, M. et al. Gastrointestinal Bleeding During the Index Hospitalization for Mechanical Circulatory Support Devices Implantation, a Nationwide Perspective. Dig Dis Sci 62, 161–174 (2017). https://doi.org/10.1007/s10620-016-4271-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-016-4271-6

Keywords

Search

Navigation