Characteristics of Gastrointestinal
Bleeding (GIB) and Subsequent
Endoscopic Therapy after Implantation
of Left Ventricular Assist Device
(LVAD) for End Stage Heart Failure
Sandeep Mahajan, David T. Majure, Amir Taefi, Julio
Salcedo, Maria E. Rodrigo, Mark Hofmeyer, George
Ruiz, Ezequiel J. Molina, Steven W. Boyce, Samer S.
Najjar, Farooq H. Sheikh
Digestive Disease Week
May 16th, 2015
LVAD Therapy Improves Survival in
Advanced Heart Failure (AHF) Patients
Rose et al., N Engl J Med. 2001;345:1435-43.
Continuous Flow LVADs
HeartMate II
HeartWare
GI Bleeding and LVAD Therapy


~15-30% of LVAD recipients develop GIB1-3
Multiple mechanisms of bleeding have been
postulated including:
1.
2.
3.
Acquired Von Willebrand Syndrome
Chronic low pulse pressure (resulting in AVM
formation)
Need for chronic anticoagulation
1. Boyle et al. J Am Coll Cardiol 2014;63:880-8.
2. Goldstein et al. J Am Coll Cardiol HF 2015;3:303-13.
3. Uriel et al. J Am Coll Cardiol 2010;56:1207-1213.
Purpose
To characterize GIB events in LVAD
recipients implanted with one of two FDA
approved LVADs at our institution
Thoratec HeartMate II,
HMII
HeartWare HVAD
Methods



Single center retrospective review of
patients implanted with a LVAD
(MedStar Washington Hospital Center)
Study period – 1/1/2011 – 10/27/2014
GIB defined as melena, hematochezia,
hematemesis, or anemia requiring
endoscopy
Methods (cont’d)
We characterized GIB events by:
1.
2.
3.
4.
Presenting signs or symptoms
Location and type of lesion
Type of endoscopy performed
Type of endoscopic therapy provided
Results
Study Characteristics
Number of patients - (no.)
170
Total follow up – (patient years)
153
Incidence of GIB – (no.) %
35 (21)
Number of GIB events – (no.)
73
Incidence GIB rate - (events per patient year)
0.22
Overall GIB event rate – (events per patient year) 0.39
Median time to first GIB event (months)
HMII
HVAD
8.2 ± 3.5
3.5 ± 0.98
(p = 0.07)
Results (cont’d)
Frequency of GI Hemorrhages
HMII
HVAD
100
Frequency of GI Hemorrhages
80
40
60
74.24
20
Percent of Patients
82.69
16.67
4.545
2
3
7.692
1.515
4.808
.9615
1.923
1.923
4
5
0
3.03
0
1
4
5
6
0
1
2
3
Number of GI Hemorrhages
Graphs by type of LVAD
9% of HMII and 10% of HVAD patients experienced more than one GIB
6
Results (cont’d)
Baseline Demographics of the GIB Study Patients (N = 35)
Age (years)
59 ± 11
Sex – no. (%)
Male
Female
26 (75)
9 (25)
Race – no. (%)
African American
Caucasian
Other
25 (71)
9 (26)
1 (3)
BMI - median
27 ± 5
Ischemic Cardiomyopathy – no. (%)
14 (40)
Diabetes – no. (%)
13 (37)
CKD > Stage 2 – no. (%)
13 (37)
Smoker (ever) – no. (%)
22 (65)
History of GIB prior to LVAD implantation
1 of 35
Results (cont’d)
Anticoagulation and presenting INR of all GIB events (N = 73)
On Warfarin
Total
On ASA
No
Yes
No
10
17
27
Yes
4
42 (58%)
46 (63%)
Total
14
59 (81%)
73
Mean INR on admission - 2.56 ± 2.07
Mean INR at the time of GIB did not differ between the 2 LVAD groups
Results (cont’d)
Presenting symptoms of all GIB events– No. (%)
Melena
34 (46)
Anemia
31 (42)
Hematemesis
4 (6)
Hematochezia
4 (6)
Results (cont’d)
A culprit lesion was identified in only 47 of 73 GIB events (67%)
Type of GIB identified - No. (%)
Angioectasias/AVM
40 (85)
Ulcer
3 (6)
Gastritis/Duodenitis
3 (6)
Polyp
1 (2)
Hemorrhoidal
0 (0)
Diverticular
0 (0)
Characteristic Image of AVM
Results (cont’d)
Esophagus = 0
Stomach
- Fundus = 4
- Body = 16 (34%)
- Antrum/Pylorus = 6
Small Intestine
- Duodenum = 4
- Jejunum = 9 (19%)
- Ileum = 0
- Cecum = 3
Colon
- Colon = 5
- Rectum = 0
Results (cont’d)
Types of procedures of all GIB events
Time to Endoscopy – mean (days)
2.56 ± 2.85
EGD – no. (%)
66 (90)
Colonoscopy – no. (%)
33 (45)
Enteroscopy – no. (%)
36 (49)
Video Capsule Endoscopy – no. (%)
5 (7)
Results (cont’d)
Type of intervention with culprit lesions (N = 47)
Argon Plasma Coagulation – no. (%)
38 (81)
Cautery – no. (%)
4 (9)
Clipping – no. (%)
1 (2)
Polyp resected – no. (%)
2 (4)
None – no. (%)
2 (4)
Limitations




Single center
Retrospective review
Use of antiplatelet therapy differs between
the 2 LVAD devices at our center
Conclusions are dependent on the accuracy
and completeness of the recorded events
Conclusion




GIB is a common complication of LVAD
therapy which frequently necessitates upper
endoscopy
Angioectasias/AVM are the most common
lesions found
Gastric body is the most common site of
GIB in our cohort
Bleeding source could not be identified in
up to 33% of cases
Future Directions



Future studies should evaluate optimal
strategies for identifying the source of bleeding
– standardized protocols
Success of primary endoscopic therapy
New investigational LVADs (introduction of
pulsatility)
Thank You



Dr. Farooq Sheikh
Dr. David T. Majure
Dr. Samer Najjar


Dr. Julio Salcedo
Dr. Amir Taefi