Efficacy of Video Capsule Endoscopy in the Management of Suspected Small Bowel Bleeding in Patients With Continuous Flow Left Ventricular Assist Devices

Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A comprehensive review

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.

Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review

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.

The incidence, risk factors, and outcomes of gastrointestinal bleeding in patients with a left ventricular assist device: a Japanese single-center cohort study

Continuous flow-left ventricular assist devices (CF-LVADs) have become a therapeutic option in the management of advanced heart failure. Several studies show that patients with CF-LVAD are at an increased risk of gastrointestinal bleeding (GIB). However, few reports have presented the characteristics of GIB in Japanese populations. We investigated the incidence, etiology, and outcome of GIB in patients with CF-LVAD. Records of adult patients who received CF-LVADs between October 2008 and January 2017 were reviewed. GIB was defined as detection of bleeding sites by any type of diagnostic imaging. 54 patients received CF-LVAD, of which eight (14%) presented with overt GIB (12 events). GIB patients are significantly older (p = 0.04) and their pre-operative inferior vena cava diameter was larger (p = 0.02). Multivariate analysis revealed that the use of Jarvik 2000 (p = 0.003) was a risk factor for GIB. In total, 85.8% of patients were free from GIB at 1 year. The most common site was the small intestine (67%). The most common cause was angiodysplasia (50%). Six patients required blood transfusion (nine events) and four underwent endoscopic clippings (five events); however, no patients needed surgeries. The incidence of GIB in our cohort was similar to the global registry data. Double balloon endoscopy is useful for diagnosis and treatment of small intestinal lesions. Future efforts to further understand the incidence of GIB in Japanese populations by multicenter data are needed.