Online Supplementary Appendices
Table of Contents
Figure S1. Gastrointestinal Bleeding Source by Cohort
Figure S2. Diagnostic Procedure Identifying Bleeding Source by Cohort
Appendix S1. Considerations with Post-operative Assessment
Echocardiographic Assessment
Post-operative transthoracic echocardiograms (TTE) were assessed when available for all
patients after placement of continuous-flow left ventricular assist device (CF-LVAD).
TTE performed between 2 and 6 months after LVAD were eligible for assessment with
preference given to the earliest TTE during this post-operative time period. Those
patients who did not have a qualifying TTE were not assessed. Pertinent data are
presented in Table S1.
Assessment of LVAD Function
Markers of LVAD function including TTE assessment of aortic valve opening and
pulsatility index (HeartMate II® only) were performed post-operatively. Aortic valve
opening was assessed via review of the TTE as presented above. Relevant data are
presented in Table S1.
PI was assessed at two time points in the post-operative setting. The average PI
over the 24 hours prior to discharge from index hospitalization was obtained. The average
PI obtained from LVAD interrogation at the first post-operative clinic visit was also
obtained when available. The mean of the pre-discharge and follow-up PI was calculated
and is presented in Table S1.
Table S1. Post-operative Echocardiographic and LVAD Function Parameters
Control
Severe RV Dysfunction
(n = 175)
(n = 37)
p Value
TAPSE*
1.03  0.28
0.98  0.34
0.49
Tei Index
0.47  0.20
0.53  0.25
0.14
RA Pressure
7.95  4.70
10.26  6.32
0.08
RVEDD
3.80  0.72
3.95  0.90
TR Severity
0.32
0.03
None
22 (14.0)
9 (26.5)
Mild
104 (66.2)
14 (41.2)
2 (1.3)
0 (0)
17 (10.8)
6 (17.6)
0 (0)
1 (2.9)
12 (7.6)
4 (11.8)
Pulsatility Index
4.97  0.71
4.95  0.92
0.93
Persistent AV Closure
104 (61.9)
24 (75)
0.38
Mild-Moderate
Moderate
Moderate-Severe
Severe
All values reported as number (%) or mean +/- SD.
*TAPSE has been shown to be an unreliable marker of RV function post-LVAD.
AV = aortic valve, RA = right atrial, RVEDD = right ventricular end diastolic
diameter, TAPSE = tricuspid annular plane systolic excursion, TR = tricuspid
regurgitation.
Appendix S2. Validation Analyses
CVP and GIB
We performed an analysis assessing the relationship between post-operative CVP and
GIB to validate our findings linking RV dysfunction and GIB. CVP is an easily
measureable post-VAD clinical marker of RV dysfunction. We obtained the postoperative CVP on post-operative day 2 or 3 on all patients with available data. We
identified 173 patients with available data and divided this group into terciles with a low
CVP tercile with CVP < 10 (58 patients), a middle tercile with CVP 10-13 (58 patients)
and a high CVP tercile with CVP ≥ 13 (57 patients). GIB was assessed over time, and a
Kaplan-Meier analysis was performed to analyze event-free survival rates. The log-rank
test was performed to determine clinical significance, and a p-value of 0.0315 was
determined.
Post-operative Inotrope Duration and GIB
We sought to perform an analysis similar to our primary analysis using a clinical
definition of RV dysfunction to further validate our findings. Accepted definitions of
post-VAD clinical RV dysfunction include prolonged duration of inotropes (≥14 days)
and need for RVAD support. Due to the markedly diminished survival and lack of
follow-up data of our patients who required RVAD support, we felt that this group would
confound our results. We opted instead to focus on duration of inotropes as a predictor of
GIB. We identified 412 patients in an expanded cohort of all patients who have received
a CF-LVAD at our institution from 2006-2014. Of this group, 112 patients required
inotropic support ≥ 14 days and compared this group with 300 patients who required <
14 days of inotropes after LVAD implantation. GIB was assessed over time, and a
Kaplan-Meier analysis was performed to analyze event-free survival rates. The Wilcoxon
test was performed to determine clinical significance, and a p-value of 0.0309 was
determined.