Intestinal angiodysplasia and aortic valve stenosis: let's not close the book on this association

Abstract

SummaryThe association between gastrointestinal (GI) bleeding due to angiodysplasia of the large intestine and calcific aortic stenosis (AS) has been a matter of debate. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. von Willebrand factor is the strongest possible link between aortic stenosis and bleeding associated with GI angiodysplasia. Physicians should be aware of this entity when dealing with elderly patients presenting either with GI bleeding or with AS. A high index of suspicion and appropriate diagnostic procedures followed by prompt treatment could be life saving. Several questions related to the pathogenesis and optimal management remain unanswered. Aortic valve replacement appears to offer the best hope of long-term resolution of the bleeding, and should be considered in most cases. The association between chronic gastrointestinal bleeding in elderly patients and aortic stenosis becomes more relevant with the advent of transcatheter aortic valve implantation which can be offered even to elderly patients with comorbidities which could make conventional surgery impossible. #

Heyde′s syndrome: An unusual cause of lower gastrointestinal bleeding

“…According to the different studies conducted to evaluate the association between aortic stenosis and gastrointestinal dysplasia, about 7-29% [3,4] of the patients with diagnosed gastrointestinal angiodysplasia suffer from aortic stenosis, and 3% of advanced aortic stenosis patients have gastrointestinal bleeding. [3] In these patients, it is postulated that the bleeding of angiodysplasia is triggered by the uncorrected severe aortic stenosis. When blood passes through the narrowed aortic valve, the turbulent flow generated causes mechanical disruption of the Von-Willebrand's multimers.…”

Treatment of Heyde's Syndrome by Aortic Valve Replacement

“…Hence, the association between these two conditions might only be a coincidence due to the concommittant senile degeneration of both the aortic valve and intestinal mucosa [2]. However, syndrome or coincidence, this combination constitutes a real threat to the elderly and its stormy complications cannot be overlooked.…”

“…With persistent anemia requiring multiple blood transfusions, aortic valve replacement should be considered, even in asymptomatic patient with a hemodynamically significant aortic stenosis [2]. …”

“…Interestingly, bleeding stops again following redo valve replacement [5]. These observations become even more relevant with the advent of transcutaneous aortic valve replacement in high risk and elderly patients with serious comorbidities [2]. …”

“…Many questions regarding its pathophysiology and treatment remain unanswered. Whether aortic valve replacement may stop gastrointestinal bleeding is still controversial, although it was suggested as early as 1974 as a first line treatment for this syndrome [1,2]. We hereby review the literature, and report a case of severe gastrointestinal bleeding from gastrointestinal tract angiodysplasia associated with aortic valve stenosis, successfully treated by aortic valve replacement.…”