Gastrointestinal Bleeding During the Index Hospitalization for Mechanical Circulatory Support Devices Implantation, a Nationwide Perspective

Gastrointestinal bleeding in recipients of left ventricular assist devices-a systematic review

The twenty-first century has revolutionized the management of congestive heart failure with the widespread use of left ventricular assist devices and other treatment modalities that improve morbidity and mortality after the failure of medical management. These novel devices come with significant side effects. One of the most common side effects of left ventricular assist devices is the increased frequency of lower gastrointestinal bleeding compared to heart failure patients without left ventricular assist devices. Multiple etiologies of recurrent gastrointestinal bleeding in such patients have been studied. The decreased amount of von Willebrand factor polymers is now recognized as one of the most common causes of increased incidence of gastrointestinal bleeding in patients with left ventricular assist devices alongside increased arteriovenous malformations. Multiple treatment modalities have been identified to prevent and treat gastrointestinal bleeding in these patients. Since the use of left ventricular assist devices is becoming more prevalent in patients with advanced heart failure, we decided to conduct this systematic review. The article summarizes the incidence, pathophysiology, and management of lower gastrointestinal bleeding in patients with left ventricular assist devices.

A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding

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.

Incidence and Outcomes of Gastrointestinal Bleeding in Patients With Percutaneous Mechanical Circulatory Support Devices

Percutaneous mechanical circulatory support (pMCS) devices are increasingly used in patients with cardiogenic shock as a bridge to recovery or bridge to decision to advanced heart failure therapies. Gastrointestinal bleeding (GIB) is a common complication that can be catastrophic. Because of the paucity of data describing the association of GIB with pMCS, we analyzed this population using the United States National Inpatient Sample database. We performed a retrospective study in patients with pMCS devices who had GIB during the index hospitalization using the National Inpatient Sample. Multivariate logistic regression analysis was performed to determine independent predictors of GIB in these patients. A total of 466,627 patients were included. We observed an overall increase in the incidence of adjusted GIB from 2.9% to 3.5% (p = 0.0025) from 2005 to 2014. In comparison to patients without GIB, those with GIB had significantly higher in-hospital mortality, length of stay, and hospitalization cost. In addition to the usual co-morbid conditions, the presence of small bowel and colonic ischemia, colon cancer, diverticulosis, chronic liver disease, and peptic ulcer disease were noted to be significant predictors of GIB for all (p <0.001). In conclusion, patients with pMCS and GIB have higher in-hospital mortality, longer length of stay, and higher cost of hospitalization. Awareness of patient risk factors for bleeding and gastrointestinal disorders are important before the use of mechanical circulatory support devices because they are associated with a substantially higher risk for bleeding.

Incidence and impact of acute kidney injury on patients with implantable left ventricular assist devices: a Meta-analysis

Background: We aimed to evaluate the acute kidney injury (AKI) incidence and its associated risk of mortality in patients with implantable left ventricular assist devices (LVAD).Methods: A systematic literature search in Ovid MEDLINE, EMBASE, and Cochrane Databases was conducted through January 2020 to identify studies that provided data on the AKI incidence and AKI-associated mortality risk in adult patients with implantable LVADs. Pooled effect estimates were examined using random-effects, generic inverse variance method of DerSimonian-Laird.Results: Fifty-six cohort studies with 63,663 LVAD patients were enrolled in this meta-analysis. The pooled incidence of reported AKI was 24.9% (95%CI: 20.1%-30.4%) but rose to 36.9% (95%CI: 31.1%-43.1%) when applying the standard definition of AKI per RIFLE, AKIN, and KDIGO criteria. The pooled incidence of severe AKI requiring renal replacement therapy (RRT) was 12.6% (95%CI: 10.5%-15.0%). AKI incidence did not differ significantly between types of LVAD (p = .35) or indication for LVAD use (p = .62). While meta-regression analysis did not demonstrate a significant association between study year and overall AKI incidence (p = .55), the study year was negatively correlated with the incidence of severe AKI requiring RRT (slope = -0.068, p < .001). The pooled odds ratios (ORs) of mortality at 30 days and one year in AKI patients were 3.66 (95% CI, 2.00-6.70) and 2.22 (95% CI, 1.62-3.04), respectively. The pooled ORs of mortality at 30 days and one year in severe AKI patients requiring RRT were 7.52 (95% CI, 4.58-12.33) and 5.41 (95% CI, 3.63-8.06), respectively.Conclusion: We found that more than one-third of LVAD patients develop AKI based on standard definitions, and 13% develop severe AKI requiring RRT. There has been a potential improvement in the incidence of severe AKI requiring RRT for LVAD patients. AKI in LVAD patients was associated with increased 30-day and 1 year mortality.

Outcomes and Predictors of Readmissions with GI Bleeding in Patients with Left Ventricular Assist Devices

OBJECTIVES

Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients.

METHODS

We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders.

RESULTS

A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, P < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, P < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, P < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, P< 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, P< 0.0001), and longer (12 vs 10.9 days, P< 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, P< 0.0001) and GI bleeding during index admission (aHR 2.68, P< 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, P = 0.14).

CONCLUSIONS

After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.