Gastrointestinal Bleeding in Patients with Ventricular Assist Devices Is Highest Immediately After Implantation

Abstract

Ventricular assist device implantation is associated with gastrointestinal bleeding (GIB); however, outcomes in terms of initial and repeat GIB risk, severity, location of lesions, and endoscopic interventions need to be better defined. Consecutive patients from a database of adult patients with ventricular assist devices (VADs) implanted between January 1, 2000, and December 31, 2010, at a single center were reviewed and followed through May 31, 2011, in a retrospective manner. The GIB events were further classified by severity, lesion location, and lesion type. Hazard analysis models were calculated for the time to GIB events. Of 166 patients with a VAD, 38 patients experienced 84 GIB events. Seventeen patients experienced ≥2 GIB events. Maximal hazard for the first bleeding event was 2.23 events/patient-year at 21 days and declined to the constant hazard by 71 days postimplantation. The hazard for recurrent GIB was greatest immediately after the first GIB event. When considering all GIB events, most lesions (68%) were located in the proximal bowel. Angiodysplasia was the most common lesion type (17.5%) seen on endoscopy when all GIB events were considered, whereas ulcers were the most common type (13.8%) seen in initial GIB events. The actuarial risk of initial GIB events peaks in the first 3 months after VAD implantation followed by a stable lower risk of bleeding. The hazard for recurrent GIB events is substantially increased immediately after the initial GIB.

Iron Deficiency Anemia

“…AVMs can lead to blood loss in patients with ventricular assist devices (VADs) and are reported in 17.5% to 30.0% of bleeding patients. 25 The lack of pulse pressure in both patients with VAD and those with severe aortic stenosis appears to be the key risk factor for AVM formation. AVMs can be due to increased sympathetic tone leading to smooth muscle relaxants or hypoperfusion leading to vascular dilatation.…”

Gastrointestinal bleeding in a patient with a continuous-flow biventricular assist device

“…As Crow observed, the rate of GI bleed in CF-LVAD patients was far higher than the rate of any bleeding expected in patients on anticoagulation for other reasons (e.g., 63 GI bleeds/100 patient-years in CF-LVAD patients vs 4.6 events/100 patient years in mechanical valve recipients) [5] . Our patient developed melena 3 wk after implantation, consistent with time to any bleeding event, including GI hemorrhage, in other studies assessing CF-LVADs and pulsatile BIVADs [4,5] . Furthermore, the transfusion of 6 units of blood to correct his hemoglobin prior to surgical resection of the diseased bowel was within the mode for first GI bleeding events in patients Late lesions include an early draining vein associated with a cluster of vessels, including capillaries lacking pre-and post-capillary sphincters.…”

“…In all 3 patients the bleeding was attributed to VMs. Since that time, much of the literature has supported VMs as a prominent source of GI bleeding in patients with CF-LVADs [4][5][6][7] . Aquired von Willebrand deficiency, prophylactic anticoagulation, and mucosal ischemia may further predispose these patients to bleeding.…”

“…However, Mirasol RV et al . GI bleeding with CF-BIVAD on those devices [4] . It is possible that the effect of CF-BIVAD therapy on GI bleeding may not be reflected by severity of bleeding in individual patients, but rather incidence of GI bleeding in the CF-BIVAD population.…”

Hemostatic complications associated with ventricular assist devices

“…The most common site of bleeding is the GI tract, with up to 5% to 40% suffering this complication . The site of bleeding can be anywhere in the GI tract and is often a challenge to diagnose, as it may be related to diffuse angiodysplasia.…”