GI bleeds prior to LVAD linked to threefold higher risk for later related hospitalization
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Patients implanted with a left ventricular assist device as destination therapy and those with a prior history of gastrointestinal bleeding were at significantly higher risk for hospitalization due to recurrent bleeding, researchers noted.
“This is the largest, multicenter study to date to explore the risk factors that result in recurrent GI bleeding in patients with LVAD implantation,” Joseph Dailey, MD, an internist at Tufts Medical Center’s division of gastroenterology, and colleagues wrote in Clinical and Translational Gastroenterology.
LVADs act as a bridge to transplant — helping with mechanical circulation of the heart while patients await a donor heart — and are now also increasingly used as life-prolonging, or destination, therapy when a patient is not suitable for transplant. The researchers noted that, from 2010 to 2019, 27,298 devices had been implanted in the United States; however, implantation is “often complicated by gastrointestinal bleeding in medically fragile patients.”
Dailey and colleagues retrospectively analyzed 475 patients (mean age, 60 years; 78% men; 84.4% white) who received an LVAD implant at Massachusetts General Hospital and Tufts Medical Center from February 2008 to January 2019. More than 25% of the patients (n = 128) had clinically significant GI bleeding. Researchers assessed patients for overt vs. occult bleeding and identified predictors of recurrent bleeding.
According to study results, 73% of patients had an overt bleed, 34% of which were from upper GI bleed sources, 3% lower GI, 0% middle GI and 54% unknown. Of the 27% of patients who had an occult bleed, 32% were from upper GI bleed sources, 25% lower GI, 13% middle GI and 27% unknown.
Techniques used to localize the source of bleeding included esophagogastroduodenoscopy, colonoscopy, enteroscopy (push and single balloon), video capsule endoscopy, tagged red blood cell scans, CT angiogram and catheter angiography with interventional radiology. Researchers were able to identify the type of bleeding lesion in 64.9% of single bleeding events and 53.4% of recurrent bleeds. The most common lesions were ulcers (20%) and arteriovenous malformations (16%).
A prior history of GI bleeding before implantation (OR = 3.85; 95% CI, 1.29-12.7) and use of LVAD as destination therapy (OR = 2.38; 95% CI, 1.05-5.58) were independently associated with higher risks for recurrent GI bleeding hospitalizations.
“Recurrent GI-bleeding remains especially challenging in this group of patients, and early identification of at-risk individuals, those with a history of pre-LVAD implant GI bleeding and destination LVAD status could allow for more deliberate pre-implantation endoscopy programs that may improve the quality of their care,” Dailey and colleagues wrote.
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