Left Ventricular Assist Device and Gastrointestinal Bleeding: Associated Factors

The incidence of gastrointestinal bleeding was noted in patients taking angiotensin II receptor blockers, and no association was found between proton pump inhibitors and gastrointestinal bleeding.

SAN ANTONIO — The most common etiology for gastrointestinal bleeding (GIB) among recipients of left ventricular assist device (LVAD) therapy was small bowel gastric arteriovenous malformations. The incidence of GIB was noted in patients taking angiotensin II receptor blockers, and no association was found between proton pump inhibitors and GIB, according to research presented at the ACG Annual Scientific Meeting, held October 25 to 30, 2019, in San Antonio, Texas.

LVAD is a common mechanical support provided to patients with advanced heart failure, and there is a well-established association between LVAD and GIB. This retrospective single-center study was designed to further investigate the clinical factors and demographics associated with GIB and the endoscopic management of GIB among LVAD recipients. Patients were randomly selected from 193 Heartware and 425 Heartmate (HMII) recipients between 2007 and 2018. Data were collected on LVAD therapy intention and settings, demographics, home medications, endoscopic reports, and echocardiograms, after which univariate analysis was performed.

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Ultimately, a total 134 Heartware patients and 188 HMII patients were included. Patients developing GIB tended to be older than those who did not (56.4 years vs 61.7 years; P =.0002), but no differences were found in race and sex. Patients developing GIB had higher baseline creatine (1.4 [0.6-3.0] vs 1.2 [0.5-3.2]; P =.0284) and lower baseline hemoglobin (10 [8.0-12.26] vs. 11 [8.0-15.5]; P <.001). A supratherapeutic international normalized ration was associated with GIB (26.7% vs 14.7%; P =.0075), and patients prescribed angiotensin II receptor blockers had a decreased incidence of GIB compared with those who were not (22.1% vs 40.3%; P =.0007), but no difference was seen in those taking proton pump inhibitors (82.2% vs 82.2%; P =1.0000).

The most common presenting sign was melena (53.4%), and bleeding lesions were most frequently located in the small bowel (42.6%). Additionally, 70.4% of identified bleeding lesions were found with push enteroscopy, 57.4% were found with esophagogastroduodenoscopy (EGD), and 41.3% were found with colonoscopy. The most common bleeding lesion etiology (patients may have more than one) was arteriovenous malformation (61.5%).

Study investigators concluded, “The majority of upper GI bleeds were within reach of a push enteroscope (proximal small bowel), which had an incremental diagnostic yield over EGD… Further development of the association between angiotensin II receptor blockers and GIB effect in LVADs are warranted. Multivariate analyses to validate these associations are in progress.”


Kalinowski DO, Kothari S, Kobeszko M, et al. Investigation of gastrointestinal bleeding among left ventricular assist device recipients. Poster presented at: ACG Annual Scientific Meeting; October 25-30, 2019; San Antonio, TX. Abstract #P0400