1
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Inglis SS, Asleh R, Iyer VN, Schettle SD, Spencer PJ, Villavicencio MA, Rodeheffer RJ, Kushwaha SS, Behfar A, Rosenbaum AN. Inhibition of angiogenesis in the management of refractory gastrointestinal bleeding in patients with LVAD support. Artif Organs 2024; 48:646-654. [PMID: 38131635 DOI: 10.1111/aor.14694] [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: 09/16/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) in patients with continuous flow left ventricular assist devices (CF-LVADs) is often related to GI angiodysplasia (GIAD). We previously reported data on VEGF inhibition with IV bevacizumab in the treatment of LVAD-associated GIAD bleeding, and now present follow-up data on patients treated with IV bevacizumab and/or low-dose oral pazopanib. METHODS All consecutive adult patients with LVAD-associated GIB from GIAD treated with bevacizumab or pazopanib, from July 20, 2017 to June 22, 2022, were included in the analysis. Data on hospitalizations, GI endoscopic procedures, and blood transfusions were obtained from first admission for GIB up to a median of 35.7 months following treatment initiation (range 1.3-59.8 months). RESULTS Eleven patients (91% male, mean 69.5 ± 8.9 years) were included. Eight patients (73%) received IV bevacizumab, two patients (18%) received oral pazopanib, and one patient (9%) received bevacizumab followed by pazopanib therapy. We observed a significantly decreased number of annualized hospitalizations for GIB (median difference - 2.87, p = 0.002), blood transfusions (median difference - 20.9, p = 0.01), and endoscopies (median difference - 6.95, p = 0.007) in patients pre- and post-anti-angiogenic therapy (bevacizumab and/or pazopanib). Similarly, a significant improvement in these clinical outcomes was noted in the bevacizumab group with decreased annualized hospitalizations (median difference - 2.75, p = 0.014), blood transfusions (median difference - 24.5, p = 0.047), and number of endoscopies (median differences -6.88, p = 0.006). CONCLUSION Anti-angiogenic therapy with IV bevacizumab and/or low-dose oral pazopanib appears to provide benefits in patients with LVAD-associated GIB with reduced hospitalizations, blood transfusions, and need for GI endoscopic procedures.
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Affiliation(s)
- Sara S Inglis
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek N Iyer
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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2
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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3
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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4
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Del Rio-Pertuz G, Nair N. Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A comprehensive review. Artif Organs 2023; 47:12-23. [PMID: 36334280 DOI: 10.1111/aor.14432] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/05/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Gastrointestinal bleeding is a major cause of morbidity that plagues the quality of life of patients supported on contemporary continuous-flow left ventricular assist devices (CF-LVADs). Despite benefits in survival and the nearly 50% reduction in complications provided by CF-LVADs, bleeding remains one of the most frequent adverse events with CF-LVAD implants. The CF-LVADs cause an increased risk of bleeding mainly due to the activation of the coagulation cascade. METHODS A literature search was done using PubMed and Google Scholar from Inception to February 2022. Qualitative analyses of the articles retrieved were used to construct this review. This review attempts to provide a comprehensive summary of the epidemiology, pathophysiology, risk stratification, and management of gastrointestinal bleeding as a complication of CF-LVAD as well as propose an algorithm for diagnosis and treatment. RESULTS Bleeding can occur at different sites in the gastrointestinal tract, the most common underlying pathology being arteriovenous malformations located in the upper gastrointestinal tract The increased prevalence of gastrointestinal (GI) bleeding in CF-LVAD patients has been attributed to the physiology of the LVAD itself, the use of anticoagulants, as well as patient comorbidities. Management involves pharmacologic and nonpharmacologic strategies. CONCLUSIONS CF-LVAD-supported patients have a significant risk of GI bleeding that is mainly caused by arteriovenous malformations located in the upper GI tract. The increased prevalence of GI bleeding in CF-LVAD patients is attributed to several etiologies that include factors attributed to the device itself and extrinsic factors such as the use of anticoagulation.
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Affiliation(s)
- Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Nandini Nair
- Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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5
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Khedr A, Mahmoud EE, Attallah N, Mir M, Boike S, Rauf I, Jama AB, Mushtaq H, Surani S, Khan SA. Role of octreotide in small bowel bleeding. World J Clin Cases 2022; 10:9192-9206. [PMID: 36159407 PMCID: PMC9477697 DOI: 10.12998/wjcc.v10.i26.9192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | | | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George School of Medicine, Grenada, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Wilson TJ, Baran DA, Herre JM, Cameron CM, Yehya A, Ingemi AI. Gastrointestinal Bleeding Rates in Left Ventricular Assist Device Population Reduced with Octreotide Utilization. ASAIO J 2021; 67:989-994. [PMID: 33369929 PMCID: PMC8404958 DOI: 10.1097/mat.0000000000001342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with continuous-flow left ventricular assist devices have a high risk of gastrointestinal bleeding (GIB) and recurrent bleeding. Studies have shown octreotide can reduce the risk of GIB. This retrospective, case-crossover study, evaluated the efficacy of octreotide for the prevention of recurrent GIB in patients with left ventricular assist devices between August 2008 and October 2018. A total of 32 patients received octreotide and were included in the study. Hospital admission for GIB was evaluated before and after the initiation of octreotide. Each case served as his/her own control. Most patients were on a reduced aspirin dose (56.2%) and had a reduced international normalized ratio goal (59.4%) before starting monthly octreotide. The most common dose of long-acting octreotide was 30 mg every 28 days. Overall, octreotide decreased the frequency of GIB (4.3 vs. 0.9 events/year, p < 0.001). Nineteen (59.4%) patients did not have a subsequent gastrointestinal bleed. Of the 13 patients who rebled after initiation of octreotide, the frequency of events decreased by 2.6 bleeds per patient per year (4.8 vs. 2.2; p = 0.043). In high-risk patients who have failed conventional therapy, octreotide can be useful for the prevention of recurrent GIB.
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Affiliation(s)
- Tyler J. Wilson
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - David A. Baran
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - John M. Herre
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Chad M. Cameron
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Amin Yehya
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Amanda I. Ingemi
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
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7
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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8
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Primary and Secondary Prevention Strategies for Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device: A Systematic Review and Network Meta-analysis. Curr Probl Cardiol 2021; 46:100835. [PMID: 33992428 DOI: 10.1016/j.cpcardiol.2021.100835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 12/21/2022]
Abstract
Recurrent gastrointestinal bleeding (GIB) is a common complication following left ventricular assist device (LVAD) implantation. Our study aimed to estimate the comparative efficacy of different pharmacologic interventions for the prevention of GIB, through a network meta-analysis (NMA). A total of 13 observational studies comparing six strategies. Among those, 4 were for primary, and 9 were for secondary prevention of GIB. On NMA, thalidomide (Hazard ratio [HR]: 0.016, Credible interval [CrI]I: 0.00053-0.12), omega-3-fatty acid (HR:0.088, CrI: 0.026-0.77), octreotide (HR: 0.17, CrI: 0.0589-0.41) and danazol (HR:0.17, CrI: 0.059-0.41) reduced the risk of GIB. The use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker (ACEi/ARB) and digoxin were not associated with any significant reduction. Based on NMA, combining indirect treatment comparisons, thalidomide, danazol, and octreotide treatments were associated with decreased risk of recurrent GIB. Additionally, Omega 3 fatty acids were associated with a lower risk of the primary episode of GIB in the LVAD patient population.
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9
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Hollis IB, Doligalski CT, Jennings DJ. Pharmacotherapy for durable left ventricular assist devices. Pharmacotherapy 2021; 41:14-27. [PMID: 33278842 DOI: 10.1002/phar.2491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the care of patients with advanced heart failure, yet still require concomitant medications in order to achieve the best possible clinical outcomes. Since the outset of routine placement of durable, continuous-flow LVADs, much of the medication management of these patients to date has been based on International Society of Heart and Lung Transplantation (ISHLT) guidance, most recently published in 2013. Since 2013, numerous multidisciplinary pharmacotherapy publications have increased the LVAD community's understanding of best practices with respect to medications. We identified the major domains of LVAD medication management and conducted a comprehensive search of US National Library of Medicine MEDLINE® database using keywords chosen to identify medication-related publications of significance dated 2013 or later. Trials pertaining to the HeartMate II™ and the HeartMate™ 3 LVADs (Abbott, Chicago, IL) and the HeartWare™ HVAD™ System (Medtronic, Minneapolis, MN) were chosen for inclusion. Highest priority for inclusion was given to prospective, randomized, controlled studies. Absent these, controlled trials (retrospective or prospective observational) were given next-highest consideration, followed by retrospective uncontrolled studies, and finally case series. Reference lists of qualified publications were reviewed to find any other publications of interest that were not discovered on initial search. Case reports were generally excluded, except where the insight gained was deemed to be uniquely pertinent. This document serves to provide a comprehensive review of the current understanding of optimal medication management in patients with durable, continuous-flow LVADs.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Christina T Doligalski
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Douglas J Jennings
- Department of Pharmacy Practice, Long Island University, New York-Presbyterian Hospital Columbia University Irving Medical Center, New York, New York, USA
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10
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Thalidomide Use Reduces Risk of Refractory Gastrointestinal Bleeding in Patients with Continuous Flow Left Ventricular Assist Devices. ASAIO J 2021; 66:645-651. [PMID: 31425265 DOI: 10.1097/mat.0000000000001054] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal (GI) bleeding is a common complication seen in patients with implanted continuous flow left ventricular assist devices (CF-LVAD), often attributed to arteriovenous malformations (AVMs). Whether thalidomide reduces recurrent GI bleeding risk in CF-LVAD patients has been incompletely evaluated. We conducted a retrospective review of all CF-LVAD patients at our institution with GI bleeding from AVMs who had a trial both off and on thalidomide. The primary endpoint was time to rebleed, while secondary endpoints included overall GI bleeding events, packed red blood cell (PRBC) transfusion requirements, and adverse events related to thalidomide. We report on 24 patients with recurrent AVM-associated GI bleeding who met criteria for and received thalidomide therapy, of which 17 had sufficient follow-up to be ultimately included for final analysis. We found the risk of rebleeding was significantly reduced in those on thalidomide therapy versus off (hazard ratio = 0.23, p = 0.022). The median number of GI bleeds per year was reduced from 4.6 to 0.4 (p = 0.0008) and the PRBC requirement was lower (36.1 vs. 0.9 units per year, p = 0.004) in those on thalidomide therapy. The adverse event rate with thalidomide was 59%, with symptoms resolution in most following dose reduction without increased bleeding. Thalidomide reduced the risk of AVM-associated GI rebleeding, number of bleeding events, and PRBC requirements in CF-LVAD patients. When initiating therapy, potential side effects and overall clinical context should be considered.
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11
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A reappraisal of the pharmacologic management of gastrointestinal bleeding in patients with continuous flow left ventricular assist devices. Heart Fail Rev 2020; 26:277-288. [PMID: 32870436 DOI: 10.1007/s10741-020-10019-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 12/28/2022]
Abstract
Advancements in the design and functionality of continuous flow left ventricular assist devices (CF-LVADs), as well as a limited number of donor hearts, have resulted in an increased utilization of this therapy among advanced heart failure (HF) patients. Despite these advancements, gastrointestinal bleeding (GIB) remains a common complication after CF-LVAD implantation. The mechanism of GIB in these patients is complex and includes a combination of angiodysplasia, platelet dysfunction, acquired von Willebrand disease, and a variety of patient-specific factors including advanced age and history of GIB. Several pharmacotherapy options have been reported in the literature, though studies supporting the use of these agents are often small, retrospective reports. Within this review, we discuss the various pharmacologic agents, their proposed mechanisms of action, and the available literature pertaining to their effectiveness and tolerability. Additionally, we propose an evidence-based treatment algorithm, encompassing the updated literature, cost of therapy, medication side effects, and ease of administration.
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12
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Vedachalam S, Balasubramanian G, Haas GJ, Krishna SG. Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review. World J Gastroenterol 2020; 26:2550-2558. [PMID: 32523310 PMCID: PMC7265145 DOI: 10.3748/wjg.v26.i20.2550] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/02/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.
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Affiliation(s)
- Srikanth Vedachalam
- Department of Internal Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Garrie J Haas
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
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13
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Converse MP, Sobhanian M, Taber DJ, Houston BA, Meadows HB, Uber WE. Effect of Angiotensin II Inhibitors on Gastrointestinal Bleeding in Patients With Left Ventricular Assist Devices. J Am Coll Cardiol 2020; 73:1769-1778. [PMID: 30975293 DOI: 10.1016/j.jacc.2019.01.051] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Angiotensin II receptor activation may result in angiogenesis, and ultimately arteriovenous malformations (AVM), through transforming growth factor (TGF)-β and angiopoietin-2 pathway activation. OBJECTIVES The goal of this study was to determine whether angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) were associated with lower risk of major gastrointestinal bleeds (GIB) and AVM-related GIBs in continuous-flow left ventricular assist device (CF-LVAD) patients. METHODS The authors reviewed HeartMate II CF-LVAD recipients between January 2009 and July 2016. Major GIBs were endoscopically confirmed requiring ≥2 U of packed red blood cells or resulting in death. ACE inhibitor/ARB dose was abstracted from medical records. ACE inhibitor/ARB exposure status was landmarked at 30 days post-operatively to avoid immortal time bias. Fine and Gray hazard models assessed the impact of ACE inhibitor/ARB therapy on major GIB and AVM-related GIB, whereas standard Cox regression assessed the impact on mortality, adjusting for baseline variables. RESULTS One-hundred and eleven patients were included with a mean 2.1 ± 1.4 years follow-up. Patients who received an ACE inhibitor/ARB within 30 days post-operatively had a 57% reduction in the risk of major GIB (adjusted hazard ratio [aHR]: 0.43; 95% confidence interval [CI]: 0.19 to 0.97; p = 0.042) and a 63% reduction in the risk of AVM-related GIB (aHR: 0.37; 95% CI: 0.16 to 0.84; p = 0.017). When the mean daily post-operative lisinopril-equivalent ACE inhibitor/ARB dose was >5 mg, the risk of major GIB decreased in a dose-threshold manner (aHR: 0.28; 95% CI: 0.09 to 0.85; p = 0.025). CONCLUSIONS ACE inhibitor/ARB therapy is associated with a protective effect of developing GIBs in CF-LVAD patients, with a dose threshold of >5 mg of daily lisinopril equivalence, possibly due to prevention of AVM formation.
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Affiliation(s)
- Maureen P Converse
- Department of Pharmacy Services, University of Florida Health Shands Hospital, Gainesville, Florida.
| | - Minoosh Sobhanian
- Department of Pharmacy Services, Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| | - David J Taber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Holly B Meadows
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Walter E Uber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
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14
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The Predicament of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device: Pathophysiology, Evaluation, and Management. Cardiol Rev 2020; 27:222-229. [PMID: 30365405 DOI: 10.1097/crd.0000000000000235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure affects over 5 million Americans, with numbers expected to rise. While heart transplantation is the most effective long-term strategy for end-stage heart failure, there is a limited cardiac donor pool, and these organs are often unavailable at the time of need. Left ventricular assist devices, therefore, continue to be used to bridge this gap. Originally implanted as a bridge to transplant, these devices are now additionally utilized as destination therapy for patients ineligible for transplant. With the widespread applicability of these devices for not just temporary measures, but also for prolonged use, the short- and long-term impact on other organ systems has become more evident. For example, gastrointestinal (GI) bleeding, with an incidence approaching 30%, is one such complication post-continuous-flow left ventricular assist device implantation. This high incidence of GI bleeding is thought to stem from a combination of factors, including the need for concomitant anticoagulant and antiplatelet therapy, and intrinsic device-related properties resulting in acquired Von Willebrand disease and arteriovenous malformations. Due to the significant morbidity associated with these GI bleeding events, a standardized protocol optimizing medical and endoscopic management, alongside close coordination between the gastroenterology and cardiology services, should be advocated for and ultimately employed.
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Nakajima-Doi S, Seguchi O, Shintani Y, Fujita T, Fukushima S, Matsumoto Y, Eura Y, Kokame K, Miyata S, Matsuda S, Mochizuki H, Iwasaki K, Kimura Y, Toda K, Kumai Y, Kuroda K, Watanabe T, Yanase M, Kobayashi J, Fukushima N. Experience of the use of octreotide for refractory gastrointestinal bleeding in a patient with Jarvik2000 ® left ventricular assist device. J Artif Organs 2019; 22:334-337. [PMID: 31338629 DOI: 10.1007/s10047-019-01121-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Gastrointestinal bleeding (GIB) is among the major complications affecting implantable continuous-flow left ventricular assist device (iLVAD) recipients and is the major cause of re-hospitalization. GIB in iLVAD recipients is sometimes critical, and controlling bleeding using conventional approaches is difficult. A 35-year-old woman developed refractory GIB from multiple gastric polyps and de novo angiodysplasia after Jarvik2000® iLVAD implantation. Discontinuation of anticoagulation and antiplatelet therapies had little effect on GIB; thus, multiple endoscopic hemostatic therapies were performed. However, bleeding recurred several times, and red blood cell (RBC) transfusion in large volumes was required for progressive anemia. Furthermore, the von Willebrand factor (VWF) multimer analysis revealed loss of the high-molecular weight multimer, which may have resulted from the high-speed rotation of the axial-flow LVAD pump. To supplement VWF, cryoprecipitate was administered, but it was effective for only several days. Finally, the patient was treated with octreotide, a somatostatin analog, on post-operative day 58. After starting octreotide, tarry stool gradually decreased, and progression of anemia slowed down within the first 14 days of treatment; thus, the total RBC transfusion volume was reduced without additional hemostatic interventions, including cryoprecipitate administration. The patient developed mediastinitis on post-operative day 68 and died of sepsis on post-operative day 72. There was no adverse effect associated with octreotide use. Although the observation period was short, octreotide appears to be useful for resolving recurrent GIB after iLVAD implantation and reducing blood transfusions.
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Affiliation(s)
- Seiko Nakajima-Doi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Yasuhiro Shintani
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoyuki Fujita
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satsuki Fukushima
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yorihiko Matsumoto
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuka Eura
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shigeki Miyata
- Department of Transfusion Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroki Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Keiichiro Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Yuki Kimura
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Koichi Toda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Yuto Kumai
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Kensuke Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shin-machi, Suita, 564-8565, Osaka, Japan.
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Arteriovenous malformations respond poorly to argon plasma coagulation in patients with continuous flow left ventricular assist devices. Eur J Gastroenterol Hepatol 2019; 31:792-798. [PMID: 31150365 DOI: 10.1097/meg.0000000000001427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastrointestinal bleeding in patients with continuous flow left ventricular assist devices (LVADs) causes significant morbidity. Arteriovenous malformations (AVMs) cause 30-60% of bleeds, yet the efficacy of endoscopic interventions and risk factors for rebleeding have not been studied. PATIENTS AND METHODS The charts of all LVAD patients undergoing endoscopy for gastrointestinal bleeding at Stanford between January 2010 and December 2017 were reviewed. Cox proportional hazard modeling was used to evaluate risk factors for rebleeding, including the type of endoscopic treatment, patient characteristics, and endoscopic findings. RESULTS Of 54 total LVAD patients presenting with gastrointestinal bleeding, 23 (42.6%) had AVMs documented on endoscopy. Treatment with argon plasma coagulation (APC) alone was associated with a higher risk of rebleeding compared to no treatment [hazard ratio (HR)=4.77, P=0.012], and compared with clip±APC (HR=7.47, P=0.012). The 90-day bleed-free rate was 10.9% with APC, 100% with clipping±APC, and 83.3% with no endoscopic treatment. Additional risk factors for rebleeding included the presence of gastric AVMs (HR=3.64, P=0.024), and presence of hematochezia (HR=5.15, P=0.05). In a multiple Cox regression model, only the presence of gastric AVMs (HR=5.50, P=0.029) and APC use (HR=14.3, P=0.008) remained significant predictors of rebleeding. CONCLUSION The use of APC alone for the treatment of AVMs in LVAD patients had a high failure rate. The presence of gastric AVMs was a significant risk factor for rebleeding in LVAD patients. Management decisions should take these factors into account.
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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18
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Rauch A, Susen S, Zieger B. Acquired von Willebrand Syndrome in Patients With Ventricular Assist Device. Front Med (Lausanne) 2019; 6:7. [PMID: 30805339 PMCID: PMC6371037 DOI: 10.3389/fmed.2019.00007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/11/2019] [Indexed: 01/27/2023] Open
Abstract
During the last decade the use of ventricular assist devices (VADs) for patients with severe heart failure has increased tremendously. However, flow disturbances, mainly high shear induced by the device is associated with bleeding complications. Shear stress-induced changes in VWF conformation are associated with a loss of high molecular weight multimers (HMW) of VWF and an increased risk of bleeding. This phenomenon and its cause will be elaborated and reviewed in the following.
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Affiliation(s)
- Antoine Rauch
- INSERM, U1011, Univ. Lille, U1011-EGID, Institut Pasteur de Lille, Lille, France.,CHU Lille, Hematology and Transfusion, Lille, France
| | - Sophie Susen
- INSERM, U1011, Univ. Lille, U1011-EGID, Institut Pasteur de Lille, Lille, France.,CHU Lille, Hematology and Transfusion, Lille, France
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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Imamura T, Kinugawa K, Uriel N. Therapeutic Strategy for Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device. Circ J 2018; 82:2931-2938. [DOI: 10.1253/circj.cj-18-0883] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center
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20
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Kim JH, Brophy DF, Shah KB. Continuous-Flow Left Ventricular Assist Device–Related Gastrointestinal Bleeding. Cardiol Clin 2018; 36:519-529. [DOI: 10.1016/j.ccl.2018.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Juricek C, Imamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, Raikhelkar J, Ota T, Song T, Burkhoff D, Sayer G, Jeevanandam V, Uriel N. Long-Acting Octreotide Reduces the Recurrence of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device. J Card Fail 2018; 24:249-254. [PMID: 29427603 DOI: 10.1016/j.cardfail.2018.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/20/2017] [Accepted: 01/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recurrent gastrointestinal bleeding is one of the most significant adverse events in patients with left ventricular assist devices (LVADs). METHODS We enrolled LVAD patients who had received an intramuscular injection of 20 mg octreotide every 4 weeks as secondary prevention for recurrent gastrointestinal bleeding despite conventional medical therapies and repeated transfusions. The frequency of gastrointestinal bleeding and other associated clinical outcomes before and during octreotide therapy were compared. RESULTS Thirty LVAD patients (66.4 ± 8.8 years old, 16 men [53%]) received octreotide therapy for 498.8 ± 356.0 days without any octreotide-associated adverse events. The frequency of gastrointestinal bleeding was decreased significantly during octreotide therapy (from 3.4 ± 3.1 to 0.7 ± 1.3 events/year; P < .001), accompanied by significant reductions in red blood cell and flesh frozen plasma transfusions, days in hospital, and need for endoscopic procedures (P < .05 for all). CONCLUSIONS Octreotide therapy reduced the frequency of recurrent gastrointestinal bleeding and may be considered for secondary prevention.
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Affiliation(s)
- Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, New York
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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22
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Loyaga-Rendon RY, Jani M, Fermin D, McDermott JK, Vancamp D, Lee S. Prevention and Treatment of Thrombotic and Hemorrhagic Complications in Patients Supported by Continuous-Flow Left Ventricular Assist Devices. Curr Heart Fail Rep 2018; 14:465-477. [PMID: 29075955 DOI: 10.1007/s11897-017-0367-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the current knowledge in prevention and treatment of thrombotic (pump thrombosis and ischemic stroke) and bleeding (gastrointestinal and hemorrhagic stroke) complications in patients supported by continuous-flow left ventricular assist devices (CF-LVAD). RECENT FINDINGS Left ventricular assist devices (LVADs) are now widely used for the management of end-stage heart failure. Unfortunately, in spite of the indisputable positive impact LVADs have on patients, the frequency and severity of complications are limitations of this therapy. Stroke, pump thrombosis, and gastrointestinal bleeding are among the most serious and frequent complications in these patients. The balance between hemorrhagic and thrombotic complications in patients supported with CF-LVAD is difficult as most patients do not necessarily fit a "bleeder" or a "clotter" profile but rather move from one side to the other of the thrombotic/bleeding spectrum. Further research is necessary to better understand the risk factors and mechanisms involved in the development of these complications.
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Affiliation(s)
- Renzo Y Loyaga-Rendon
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA.
| | - Milena Jani
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - David Fermin
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Jennifer K McDermott
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Diane Vancamp
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Sangjin Lee
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
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Shah KB, Gunda S, Emani S, Kanwar MK, Uriel N, Colombo PC, Uber PA, Sears ML, Chuang J, Farrar DJ, Brophy DF, Smallfield GB. Multicenter Evaluation of Octreotide as Secondary Prophylaxis in Patients With Left Ventricular Assist Devices and Gastrointestinal Bleeding. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004500. [DOI: 10.1161/circheartfailure.117.004500] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/19/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Keyur B. Shah
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sampath Gunda
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sitaramesh Emani
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Manreet K. Kanwar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Nir Uriel
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Paolo C. Colombo
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Patricia A. Uber
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Melissa L. Sears
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Joyce Chuang
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - David J. Farrar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Donald F. Brophy
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - George B. Smallfield
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
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Sieg AC, Moretz JD, Horn E, Jennings DL. Pharmacotherapeutic Management of Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices. Pharmacotherapy 2017; 37:1432-1448. [DOI: 10.1002/phar.2016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Adam C. Sieg
- Department of Pharmacy; University of Kentucky; Lexington Kentucky
| | - Jeremy D. Moretz
- Department of Pharmacy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Edward Horn
- Department of Pharmacy; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - Douglas L. Jennings
- Department of Pharmacy; New York-Presbyterian Hospital - Columbia University Medical Center; New York New York
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Vuddanda V, Jazayeri MA, Turagam MK, Lavu M, Parikh V, Atkins D, Bommana S, Yeruva MR, Di Biase L, Cheng J, Swarup V, Gopinathannair R, Olyaee M, Ivaturi V, Natale A, Lakkireddy D. Systemic Octreotide Therapy in Prevention of Gastrointestinal Bleeds Related to Arteriovenous Malformations and Obscure Etiology in Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:1390-1399. [PMID: 29759670 DOI: 10.1016/j.jacep.2017.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 04/05/2017] [Accepted: 04/11/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding. BACKGROUND AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs. METHODS In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6 months' follow-up. RESULTS After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA2DS2-VASc score 3 ± 1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36 (78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and 1 required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p < 0.001). CONCLUSIONS Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief from bleeding.
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Affiliation(s)
- Venkat Vuddanda
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Mohammad-Ali Jazayeri
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Mohit K Turagam
- Division of Cardiology, University of Missouri, Columbia, Missouri
| | - Madhav Lavu
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Valay Parikh
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Donita Atkins
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Sudharani Bommana
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Madhu Reddy Yeruva
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Jie Cheng
- Texas Heart Institute, St. Luke's Hospital, Houston, Texas
| | | | | | - Mojtaba Olyaee
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Vijay Ivaturi
- Department of Pharmacy Practice and Science University of Maryland, Baltimore
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas.
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Gurvits GE, Fradkov E. Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients. World J Gastroenterol 2017; 23:3945-3953. [PMID: 28652649 PMCID: PMC5473115 DOI: 10.3748/wjg.v23.i22.3945] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/10/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023] Open
Abstract
Continuous-flow left ventricular assist devices (CF-LVADs) have significantly improved outcomes for patients with end-stage heart failure when used as a bridge to cardiac transplantation or, more recently, as destination therapy. However, its implantations carries a risk of complications including infection, device malfunction, arrhythmias, right ventricular failure, thromboembolic disease, postoperative and nonsurgical bleeding. A significant number of left ventricular assist devices (LVAD) recipients may experience recurrent gastrointestinal hemorrhage, mainly due to combination of antiplatelet and vitamin K antagonist therapy, activation of fibrinolytic pathway, acquired von Willebrand factor deficiency, and tendency to develop small intestinal angiodysplasias due to increased rotary speed of the pump. Gastrointestinal bleeding in LVAD patients remains a source of increased morbidity including the need for blood transfusions, extended hospital stays, multiple readmissions, and overall mortality. Management of gastrointestinal bleeding in LVAD patients involves multidisciplinary approach in stabilizing the patients, addressing risk factors and performing structured endoluminal evaluation with focus on upper gastrointestinal tract including jejunum to find and eradicate culprit lesion. Medical and procedural intervention is largely successful and universal bleeding cessation occurs in transplanted patients.
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