Advertisement

Digestive Diseases and Sciences

, Volume 61, Issue 6, pp 1603–1610 | Cite as

The Diagnostic Yield of Repeated Endoscopic Evaluation in Patients with Gastrointestinal Bleeding and Left Ventricular Assist Devices

  • Hassan K. DakikEmail author
  • Alyson A. McGhan
  • Shih-Ting Chiu
  • Chetan B. Patel
  • Carmelo A. Milano
  • Joseph G. Rogers
  • Shein-Chung Chow
  • Daniel M. Wild
Original Article

Abstract

Introduction

Left ventricular assist devices (LVADs) are increasingly common in patients with advanced heart failure. GI bleeding (GIB) occurs in 20–30 % of these patients and can arise anywhere in the GI tract. Given the high rates of GIB in this population, our aim was to determine the diagnostic yield of repeated endoscopic evaluation in these patients.

Methods

We performed a retrospective review of all 257 patients who had LVADs placed between 2008 and 2013 at Duke University Hospital and identified all patients who underwent any endoscopic evaluation for GIB.

Results

Of the 257 patients with LVADs placed, 78 (30 %) underwent at least one endoscopy for GIB. A source was identified in 36 % of cases, most commonly angioectasias (53.6 %). Treatment was performed in 67.9 % of patients and hemostasis was achieved in all. 64.1 % of the cohort underwent a second endoscopy for GIB. 42.9 % of these exams revealed a bleeding source. Endoscopic treatment was employed in 76.2 %. 38.5 % of the cohort underwent a third endoscopic exam for bleeding and a source was identified in 53.3 % with angioectasias remaining most common (56.3 %). By Fisher’s exact and Chi-square testing, only the presence of a bleeding source (p = 0.0034) and use of hemostatic therapy (p = 0.0127) on the index examination were significantly associated with re-bleeding.

Conclusions

GIB is common in patients with LVADs. The diagnostic and therapeutic yield of endoscopy is remains high with repeated interventions. Despite these high yields, a large portion of the cohort requires repeated interventions for recurrent bleeding.

Keywords

Left ventricular assist devices GI bleeding Angioectasia Therapeutic endoscopy 

Notes

Compliance with ethical standards

Conflict of interest

This work represents original research conducted within Duke University Health System research policies. Neither myself nor any of the authors listed above have any pertinent financial or professional conflicts of interest related to this study to disclose.

References

  1. 1.
    Kirklin JK, Naftel DC, Kormos RL, et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. 2013;32:141–156.CrossRefPubMedGoogle Scholar
  2. 2.
    Shrode CW, Draper KV, Huang RJ, et al. Significantly higher rates of gastrointestinal bleeding and thromboembolic events with left ventricular assist devices. Clin Gastroenterol Hepatol. 2014;12:1461–1467.CrossRefPubMedGoogle Scholar
  3. 3.
    Stulak JM, Lee D, Haft JW, et al. Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant. 2014;33:60–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Singh G, Albeldawi M, Kalra SS, et al. Features of patients with gastrointestinal bleeding after implantation of ventricular assist devices. Clin Gastroenterol Hepatol. 2015;13:107.e1–114.e1.Google Scholar
  5. 5.
    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.CrossRefPubMedGoogle Scholar
  6. 6.
    Islam S, Cevik C, Madonna R, et al. Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series. Clin Cardiol. 2013;36:190–200.CrossRefPubMedGoogle Scholar
  7. 7.
    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.CrossRefPubMedGoogle Scholar
  8. 8.
    Raju GS, Gerson L, Das A, Lewis B, American Gastroenterological Association. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology. 2007;133:1694–1696.CrossRefPubMedGoogle Scholar
  9. 9.
    Suarez J, Patel CB, Felker GM, et al. Mechanisms of bleeding and approach to patients with axial-flow left ventricular assist devices. Circ Heart Fail. 2011;4:779–784.CrossRefPubMedGoogle Scholar
  10. 10.
    Meyer AL, Malehsa D, Bara C, et al. Acquired von Willebrand syndrome in patients with an axial flow left ventricular assist device. Circ Heart Fail. 2010;3:675–681.CrossRefPubMedGoogle Scholar
  11. 11.
    Tsai HM, Sussman II, Nagel RL. Shear stress enhances the proteolysis of von Willebrand factor in normal plasma. Blood. 1994;83:2171–2179.PubMedGoogle Scholar
  12. 12.
    Crow S, Chen D, Milano C, et al. Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg. 2010;90:1263–1269.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    Crow S, John R, Boyle A, et al. Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg. 2009;137:208–215.CrossRefPubMedGoogle Scholar
  15. 15.
    Boyle AJ, Russell SD, Teuteberg JJ, et al. Low thromboembolism and pump thrombosis with the HeartMate II left ventricular assist device: analysis of outpatient anti-coagulation. J Heart Lung Transplant. 2009;28:881–887.CrossRefPubMedGoogle Scholar
  16. 16.
    Menon AK, Götzenich A, Sassmannshausen H, et al. Low stroke rate and few thrombo-embolic events after HeartMate II implantation under mild anticoagulation. Eur J Cardiothorac Surg. 2012;42:319–323.CrossRefPubMedGoogle Scholar
  17. 17.
    Najjar SS, Slaughter MS, Pagani FD, et al. An analysis of pump thrombus events in patients in the HeartWare ADVANCE bridge to transplant and continued access protocol trial. J Heart Lung Transplant. 2014;33:23–34.CrossRefPubMedGoogle Scholar
  18. 18.
    Starling RC, Moazami N, Silvestry SC, et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med. 2014;370:33–40.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Division of GastroenterologyDuke University HospitalDurhamUSA
  2. 2.Division of CardiologyDuke University HospitalDurhamUSA
  3. 3.Division of BiostatisticsDuke University HospitalDurhamUSA
  4. 4.Division of Cardiothoracic SurgeryDuke University HospitalDurhamUSA

Personalised recommendations