characteristics of gastrointestinal bleeding (gib) and subsequent endoscopic therapy after...
TRANSCRIPT
Characteristics of Gastrointestinal Bleeding (GIB) and Subsequent Endoscopic Therapy after Implantation of Left Ventricular Assist Device (LVAD) for End Stage Heart Failure
Sandeep Mahajan, David T. Majure, Amir Taefi, Julio Salcedo, Maria E. Rodrigo, Mark Hofmeyer, George Ruiz, Ezequiel J. Molina, Steven W. Boyce, Samer S. Najjar, Farooq H. Sheikh
Digestive Disease Week
May 16th, 2015
LVAD Therapy Improves Survival in Advanced Heart Failure (AHF) Patients
Rose et al., N Engl J Med. 2001;345:1435-43.
Continuous Flow LVADs
HeartMate II HeartWare
GI Bleeding and LVAD Therapy
~15-30% of LVAD recipients develop GIB1-3 Multiple mechanisms of bleeding have been
postulated including: 1. Acquired Von Willebrand Syndrome
2. Chronic low pulse pressure (resulting in AVM formation)
3. Need for chronic anticoagulation
1. Boyle et al. J Am Coll Cardiol 2014;63:880-8.2. Goldstein et al. J Am Coll Cardiol HF 2015;3:303-13.3. Uriel et al. J Am Coll Cardiol 2010;56:1207-1213.
Purpose
To characterize GIB events in LVAD recipients implanted with one of two FDA
approved LVADs at our institution
Thoratec HeartMate II, HMII
HeartWare HVAD
Methods
Single center retrospective review of patients implanted with a LVAD
(MedStar Washington Hospital Center)
Study period – 1/1/2011 – 10/27/2014
GIB defined as melena, hematochezia, hematemesis, or anemia requiring endoscopy
Methods (cont’d)
We characterized GIB events by:1. Presenting signs or symptoms
2. Location and type of lesion
3. Type of endoscopy performed
4. Type of endoscopic therapy provided
ResultsStudy Characteristics
Number of patients - (no.) 170
Total follow up – (patient years) 153
Incidence of GIB – (no.) % 35 (21)
Number of GIB events – (no.) 73
Incidence GIB rate - (events per patient year) 0.22
Overall GIB event rate – (events per patient year) 0.39
Median time to first GIB event (months)HMIIHVAD
8.2 ± 3.5 3.5 ± 0.98 (p = 0.07)
Results (cont’d)
9% of HMII and 10% of HVAD patients experienced more than one GIB
Results (cont’d)
Baseline Demographics of the GIB Study Patients (N = 35)
Age (years) 59 ± 11
Sex – no. (%)MaleFemale
26 (75)9 (25)
Race – no. (%)African AmericanCaucasianOther
25 (71)9 (26)1 (3)
BMI - median 27 ± 5
Ischemic Cardiomyopathy – no. (%) 14 (40)
Diabetes – no. (%) 13 (37)
CKD > Stage 2 – no. (%) 13 (37)
Smoker (ever) – no. (%) 22 (65)
History of GIB prior to LVAD implantation 1 of 35
Results (cont’d)
Anticoagulation and presenting INR of all GIB events (N = 73)
On Warfarin Total
On ASA No Yes
No 10 17 27
Yes 4 42 (58%) 46 (63%)
Total 14 59 (81%) 73
Mean INR on admission - 2.56 ± 2.07
Mean INR at the time of GIB did not differ between the 2 LVAD groups
Results (cont’d)
Presenting symptoms of all GIB events– No. (%)
Melena 34 (46)
Anemia 31 (42)
Hematemesis 4 (6)
Hematochezia 4 (6)
Results (cont’d)
Type of GIB identified - No. (%)
Angioectasias/AVM 40 (85)
Ulcer 3 (6)
Gastritis/Duodenitis 3 (6)
Polyp 1 (2)
Hemorrhoidal 0 (0)
Diverticular 0 (0)
A culprit lesion was identified in only 47 of 73 GIB events (67%)
Characteristic Image of AVM
Results (cont’d)
Esophagus = 0
Stomach- Fundus = 4- Body = 16 (34%)- Antrum/Pylorus = 6
Small Intestine- Duodenum = 4- Jejunum = 9 (19%)- Ileum = 0- Cecum = 3
Colon- Colon = 5 - Rectum = 0
Results (cont’d)
Types of procedures of all GIB events
Time to Endoscopy – mean (days) 2.56 ± 2.85
EGD – no. (%) 66 (90)
Colonoscopy – no. (%) 33 (45)
Enteroscopy – no. (%) 36 (49)
Video Capsule Endoscopy – no. (%) 5 (7)
Results (cont’d)
Type of intervention with culprit lesions (N = 47)
Argon Plasma Coagulation – no. (%) 38 (81)
Cautery – no. (%) 4 (9)
Clipping – no. (%) 1 (2)
Polyp resected – no. (%) 2 (4)
None – no. (%) 2 (4)
Limitations
Single center Retrospective review Use of antiplatelet therapy differs between
the 2 LVAD devices at our center Conclusions are dependent on the accuracy
and completeness of the recorded events
Conclusion
GIB is a common complication of LVAD therapy which frequently necessitates upper endoscopy
Angioectasias/AVM are the most common lesions found
Gastric body is the most common site of GIB in our cohort
Bleeding source could not be identified in up to 33% of cases
Future Directions Future studies should evaluate optimal
strategies for identifying the source of bleeding – standardized protocols
Success of primary endoscopic therapy New investigational LVADs (introduction of
pulsatility)
Thank You
Dr. Farooq Sheikh Dr. David T. Majure Dr. Samer Najjar
Dr. Julio Salcedo Dr. Amir Taefi