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Kondo M, Nagasue T, Torisu T, Miyazono S, Matsuno Y, Nagahata T, Hashimoto T, Fujino T, Shiose A, Kitazono T. Use of endoscopic hand-suturing to treat refractory bleeding from a gastric ulcer in a patient with a left ventricular assist device. DEN OPEN 2024; 4:e369. [PMID: 38638286 PMCID: PMC11024503 DOI: 10.1002/deo2.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/30/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024]
Abstract
We herein describe a 49-year-old man with severe heart failure due to fulminant myocarditis who underwent left ventricular assist device implantation and received clopidogrel and warfarin as antithrombotic agents. The patient developed anemia secondary to chronic bleeding gastric hyperplastic polyps, necessitating endoscopic mucosal resection. Despite attempts to manage post-endoscopic mucosal resection bleeding from a gastric ulcer by endoscopic hemostasis using hemostatic forceps, local hemostatic agents, and polyglycolic acid sheets, the bleeding persisted. Hemostasis of the refractory bleeding was finally achieved by endoscopic hand-suturing of the ulcer. One month later, the ulcer was almost completely scarred. This case has important clinical value in that it demonstrates the efficacy of endoscopic hand-suturing even in challenging cases such as refractory bleeding gastric ulcers in patients with left ventricular assist devices.
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Affiliation(s)
- Masahiro Kondo
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tomohiro Nagasue
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takehiro Torisu
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Satoshi Miyazono
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Yuichi Matsuno
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takahisa Nagahata
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Toru Hashimoto
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary FailureGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Akira Shiose
- Department of Cardiovascular SurgeryGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takanari Kitazono
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
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Mohamed WT, Jahagirdar V, Jaber F, Ahmed MK, Ghoz HM, Sperry BW, Clarkston WK. Pre- and Post-Implant Endoscopy in Left Ventricular Assist Device Recipients: A Single-Center Experience. Gastroenterology Res 2024; 17:1-9. [PMID: 38463148 PMCID: PMC10923248 DOI: 10.14740/gr1661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/04/2024] [Indexed: 03/12/2024] Open
Abstract
Background Gastrointestinal bleeding (GIB) is common in left ventricular assist devices (LVADs) patients, but the optimal screening approach before LVAD implantation is still unclear. The aim of the study was to describe our experience with pre- and post-LVAD implantation endoscopic screening and subsequent GI bleeding in this cohort. Methods A retrospective review was conducted among all patients who underwent LVAD implantation at Saint Luke's Hospital, between 2010 and 2020. The data were reviewed to determine the yield and safety of endoscopic procedures performed within 1 month before LVAD placement and the incidence of GIB within 1 year after implantation. Results A total of 167 LVAD patients met the inclusion criteria, and 23 underwent pre-implantation endoscopic evaluation. Angiodysplasia had a significantly higher odds ratio (OR) of 9.41 (95% confidence interval (CI): 2.01 - 44.09) in post-LVAD endoscopy, while there was no significant difference in bleeding from other sources such as peptic ulcer disease or diverticular bleeding. There was no difference in the incidence of GIB in patients who underwent endoscopic evaluation pre-LVAD compared to post-LVAD GIB (32.6% vs. 39.1%, P = 0.64). Endoscopy was well-tolerated in this cohort, and argon plasma coagulation was the most commonly used intervention to achieve hemostasis. Conclusions According to our results, we recommend against routine pre-LVAD endoscopic screening. Instead, we suggest an individualized approach, where decisions are made on a case-by-case basis.
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Affiliation(s)
- Wael T. Mohamed
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mohamed K. Ahmed
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Hassan M. Ghoz
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Brett W. Sperry
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Wendell K. Clarkston
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Gastroenterology, Saint Luke’s Hospital, Kansas City, MO, USA
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Kominami K, Akino M. Partial Pressure of End-Tidal Oxygen and Blood Lactate During Cardiopulmonary Exercise Testing in Healthy Older Participants and Patients at Risk of Cardiac Disease. Cardiol Res 2024; 15:29-36. [PMID: 38464709 PMCID: PMC10923256 DOI: 10.14740/cr1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/03/2024] [Indexed: 03/12/2024] Open
Abstract
Background The partial pressure of end-tidal oxygen (PETO2) and end-tidal oxygen concentration (ETO2) are among the indices that can be measured by exhaled gas analysis. Several observational studies have shown that skeletal muscle function is impaired in patients with cardiac disease; thus, the assessment of skeletal muscle function is important. Additionally, although it has recently been suggested that the difference in PETO2 from rest to the ventilatory anaerobic threshold (VAT) reflects oxygen availability in peripheral factors, primarily skeletal muscle, the evidence for this is not well established. Therefore, we hypothesized and investigated whether increased blood lactate (BLa) levels, resulting from decreased skeletal muscle and mitochondrial oxygen availability, and PETO2 dynamics during cardiopulmonary exercise testing (CPET) would be related. Methods All participants performed the symptomatic limited CPET, and their BLa levels were measured. The difference in PETO2 and ETO2 from rest to VAT determined by the V-slope method (ΔPETO2 and ΔETO2) was calculated and compared with the increase in BLa due to exercise testing. Results We recruited 22 healthy older participants (nine males; 69.4 ± 6.8 years) and 11 patients with cardiovascular risk (eight males; 73.0 ± 8.8 years). ΔPETO2 and ΔETO2 did not differ between the two groups (P = 0.355 and P = 0.369, respectively), showing no correlation between increase in BLa from rest to VAT, but were significantly correlated with an increase in BLa from rest to the end of exercise (ΔPETO2, P = 0.030; ΔETO2, P = 0.029). The correlation was particularly pronounced among those at cardiovascular risk (ΔPETO2, P = 0.012; ΔETO2, P = 0.011). Conclusions ΔPETO2 and ΔETO2 from rest to VAT during CPET may be useful as indices reflecting skeletal muscle oxygen utilization capacity.
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Affiliation(s)
- Kazuyuki Kominami
- Department of Rehabilitation, Sanseikai Kitano Hospital, 6-30, 1- chome, Kitano 1-jyo, Kiyota-ku, Sapporo, Hokkaido 004-0861, Japan
| | - Masatoshi Akino
- Department of Internal Medicine, Sapporo Kiyota Hospital, 1-1, 1-chome, Shin-ei 1-jyo, Kiyota-ku, Sapporo, Hokkaido 004-0831, Japan
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Sherazi S, Alexis JD, McNitt S, Polonsky B, Shah S, Younis A, Kutyifa V, Vidula H, Gosev I, Goldenberg I. Racial differences in clinical characteristics and readmission burden among patients with a left ventricular-assist device. Artif Organs 2023; 47:1242-1249. [PMID: 36820756 DOI: 10.1111/aor.14506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND There are limited data regarding racial disparities in outcomes after left ventricular assist device (LVAD) implantation. The purpose of this study was to compare clinical characteristics and the burden of readmissions by race among patients with LVAD. METHODS The study population included 461 patients implanted with LVADs at the University of Rochester Medical Center, NY from May 2008 to March 2020. Patients were stratified by race as White patients (N = 396 [86%]) and Black patients (N = 65 [14%]). The Anderson-Gill recurrent regression analysis was used to assess the independent association between race and the total number of admissions after LVAD implant during an average follow-up of 2.45 ± 2.30 years. RESULTS Black patients displayed significant differences in baseline clinical characteristics compared to White patients, including a younger age, a lower frequency of ischemic etiology, and a higher baseline serum creatinine. Black patients had a significantly higher burden of readmissions after LVAD implantation as compared with White patients 10 versus 7 (average number of hospitalizations per patient at 5 years of follow-up, respectively) translated into a significant 39% increased risk of recurrent readmissions after multivariate adjustment (Hazard ratio 1.39, 95% CI; 1.07-1.82, p 0.013). CONCLUSION Black LVAD patients experience an increased burden of readmissions compared with White patients, after adjustment for baseline differences in demographics and clinical characteristics. Future studies should assess the underlying mechanisms for this increased risk including the effect of social determinants of health on the risk of readmissions in LVAD recipients.
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Affiliation(s)
- Saadia Sherazi
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jeffrey D Alexis
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Bronislava Polonsky
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Suhaib Shah
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Arwa Younis
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Valentina Kutyifa
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Himabindu Vidula
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiothoracic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Dailey J, Nguyen LH, Kohli A, Ha JB, Russell MB, Dhingra R, Kiernan MS, Thomas MF, Coglianese EC, Sterling MJ, Yacavone RF, Natov N, Richter JM. A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding. Clin Transl Gastroenterol 2022; 13:e00526. [PMID: 36007177 PMCID: PMC9624495 DOI: 10.14309/ctg.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients. METHODS We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB. RESULTS We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05-5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29-12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization. DISCUSSION Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.
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Affiliation(s)
- Joseph Dailey
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Long H. Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Clinical and Translational Epidemiology Unit, Boston, Massachusetts, USA
| | - Arushi Kohli
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Jasmine B. Ha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael B. Russell
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rohit Dhingra
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michael S. Kiernan
- Department of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Molly F. Thomas
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin C. Coglianese
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts, USA
| | - Mark J. Sterling
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Robert F. Yacavone
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nikola Natov
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Decreased Platelet Specific Receptor Expression of P-Selectin and GPIIb/IIIa Predict Future Non-Surgical Bleeding in Patients after Left Ventricular Assist Device Implantation. Int J Mol Sci 2022; 23:ijms231810252. [PMID: 36142161 PMCID: PMC9499488 DOI: 10.3390/ijms231810252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Non-surgical bleeding (NSB) is one of the major clinical complications in patients under continuous-flow left ventricular assist device (LVAD) support. The increased shear stress leads to an altered platelet receptor composition. Whether these changes increase the risk for NSB is unclear. Thus, we compared the platelet receptor composition of patients with (bleeder group, n = 18) and without NSB (non-bleeder group, n = 18) prior to LVAD implantation. Blood samples were obtained prior to LVAD implantation and after bleeding complications in the post-implant period. Platelet receptor expression of GPIbα, GPIIb/IIIa, P-selectin and CD63 as well as intra-platelet oxidative stress levels were quantified by flow cytometry. Bleeders and non-bleeders were comparable regarding clinical characteristics, von Willebrand factor diagnostics and the aggregation capacity before and after LVAD implantation (p > 0.05). LVAD patients in the bleeder group suffered from gastrointestinal bleeding (33%; n = 6), epistaxis (22%; n = 4), hematuria or hematoma (17%; n = 3, respectively) and cerebral bleeding (11%; n = 2). Prior to LVAD implantation, a restricted surface expression of the platelet receptors P-selectin and GPIIb/IIIa was observed in the bleeder group (P-selectin: 7.2 ± 2.6%; GPIIb/IIIa: 26,900 ± 13,608 U) compared to non-bleeders (P-selectin: 12.4 ± 8.1%, p = 0.02; GPIIb/IIIa: 36,259 ± 9914 U; p = 0.02). We hypothesized that the reduced platelet receptor expression of P-selectin and GPIIb/IIIa prior to LVAD implantation may be linked to LVAD-related NSB.
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Sheikh FH, Ravichandran AK, Goldstein DJ, Agarwal R, Ransom J, Bansal A, Kim G, Cleveland JC, Uriel N, Sheridan BC, Chomsky D, Patel SR, Dirckx N, Franke A, Mehra MR. Impact of Race on Clinical Outcomes After Implantation With a Fully Magnetically Levitated Left Ventricular Assist Device: An Analysis From the MOMENTUM 3 Trial. Circ Heart Fail 2021; 14:e008360. [PMID: 34525837 DOI: 10.1161/circheartfailure.120.008360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure disproportionately affects Black patients. Whether differences among race influence outcomes in advanced heart failure with use of a fully magnetically levitated continuous-flow left ventricular assist device remains uncertain. METHODS We included 515 IDE (Investigational Device Exemption) clinical trial patients and 500 Continued Access Protocol patients implanted with the HeartMate 3 left ventricular assist device in the MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3). Outcomes were compared between Black and White left ventricular assist device recipients for the primary end point of survival free of disabling stroke or reoperation to replace or remove a malfunctioning device at 2 years, overall survival, adverse events, 6-minute walk distance, and quality of life scores. RESULTS Of 1015 HeartMate 3 patients, 675 were self-identified as White and 285 as Black individuals. The Black patient cohort was younger, more obese and with a history of hypertension, and more nonischemic cause of heart failure, relative to the White patient group. Black and White patients did not experience a difference in the primary end point (81.1% versus 77.9%; hazard ratio, 1.08 [95% CI, 0.76-1.54], P=0.6568). Black patients were at higher risk of adverse events (calculated as events per 100 patient-years), including bleeding (75.4 versus 63.5; P<0.0001), stroke (9.5 versus 7.2; P=0.0183), and hypertension (10.1 versus 3.2; P<0.0001). The 6-minute walk distance was not different at baseline and 6 months between the groups, however, the absolute change from baseline was greater for White patients (median: +183.0 [interquartile range, 42.0-335.3] versus +163.8 [interquartile range, 42.3-315.0] meters, P=0.01). The absolute quality of life measurement (EuroQoL group, 5-dimension, 5-level instrument visual analog scale) at baseline and 6 months was better in the Black patient group, but relative improvement from baseline to 6 months was greater in White patients (median: +20.0 [interquartile range, 5.0-40.0] versus +25.0 [interquartile range, 10.0-45.0]; P=0.0298). CONCLUSIONS Although the survival free of disabling stroke or reoperation to replace/remove a malfunctioning device at 2 years with the HM 3 left ventricular assist device did not differ by race, Black HeartMate 3 patients experienced a higher morbidity burden and smaller gains in functional capacity and quality of life when compared with White patients. These findings require efforts designed to better understand and overcome these gaps through systematic identification and tackling of putative factors. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02224755 and NCT02892955.
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Affiliation(s)
- Farooq H Sheikh
- Medstar Heart and Vascular Institute, Washington, DC (F.H.S.)
| | | | | | | | - John Ransom
- Baptist Health, Heart and Transplant Institute, Little Rock, AR (J.R.)
| | | | - Gene Kim
- University of Chicago Medical Center, IL (G.K.)
| | | | - Nir Uriel
- New York Presbyterian and Columbia University (N.U.)
| | | | | | | | - Nick Dirckx
- Global Biometrics, Abbott, Plymouth, MN (N.D.)
| | - Abi Franke
- Global Clinical Affairs - Heart Failure, Abbott, Sylmar, CA (A.F.)
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA (M.R.M.)
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Palchaudhuri S, Dhawan I, Parsikia A, Birati EY, Wald J, Siddique SM, Fisher LR. Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices? A retrospective study. World J Gastroenterol 2021; 27:3877-3887. [PMID: 34321851 PMCID: PMC8291026 DOI: 10.3748/wjg.v27.i25.3877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/19/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with left ventricular assist devices (LVADs) are at increased risk for recurrent gastrointestinal bleeding (GIB) and repeat endoscopic procedures. We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.
AIM To evaluate for an association between endoscopic intervention and subsequent GIB. Secondary aims were to assess the frequency of GIB in our cohort, describe GIB presentations and sources identified, and determine risk factors for recurrent GIB.
METHODS We conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011 – December 2018 and assessed all hospital encounters for GIB through December 2019. We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed. We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.
RESULTS In the cohort of 295 patients, 97 (32.9%) had at least one GIB hospital encounter. There were 238 hospital encounters, with 55.4% (132/238) within the first year of LVAD implantation. GIB resolved on its own by discharge in 69.8% (164/235) encounters. Recurrent GIB occurred in 55.5% (54/97) of patients, accounting for 59.2% (141/238) of all encounters. Of the 85.7% (204/238) of encounters that included at least one endoscopic evaluation, an endoscopic intervention was performed in 34.8% (71/204). The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant (odds ratio 1.18, P = 0.58).
CONCLUSION Patients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures. In this retrospective cohort study, adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB, thus suggesting the uniqueness of the LVAD population. A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.
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Affiliation(s)
- Sonali Palchaudhuri
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Ishita Dhawan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Afshin Parsikia
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Edo Y Birati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Joyce Wald
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Shazia Mehmood Siddique
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Laurel R Fisher
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
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Loyaga-Rendon RY, Kazui T, Acharya D. Antiplatelet and anticoagulation strategies for left ventricular assist devices. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:521. [PMID: 33850918 PMCID: PMC8039667 DOI: 10.21037/atm-20-4849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.
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Affiliation(s)
| | - Toshinobu Kazui
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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