How to manage patients with Gastrointestinal Angiodysplasia (GAVE) syndrome and aortic stenosis?

From the Guidelines

Management of patients with GAVE syndrome and aortic stenosis should prioritize endoscopic band ligation (EBL) for GAVE, given its superiority in reducing transfusion requirements and improving hemoglobin levels, as evidenced by a recent study 1.

GAVE Management

For GAVE management, the following approaches can be considered:

• Endoscopic therapy is the first-line treatment, with endoscopic band ligation (EBL) being the preferred modality, as it has been shown to lead to decreased blood loss and reduced red blood cell transfusion requirements, with a greater decrease in transfusion requirements compared to other endoscopic thermal therapies 1.
• Radiofrequency ablation or other endoscopic thermal methods may be considered for refractory cases.
• Pharmacological options, such as octreotide, tranexamic acid, or thalidomide, may be used for patients who cannot undergo endoscopic therapy.

Aortic Stenosis Management

For aortic stenosis management:

• Cardiac evaluation is essential before any GAVE interventions.
• Transcatheter aortic valve replacement (TAVR) or surgical valve replacement should be considered for severe aortic stenosis, as recommended by guidelines 1.
• Blood management is crucial, with a hemoglobin target above 8 g/dL using iron supplementation and transfusions as needed.
• Anticoagulation and antiplatelet therapy should be minimized when possible, though this requires careful balancing if the patient has cardiac stents or mechanical valves.

Coordination of Care

A coordinated approach addressing both GAVE and aortic stenosis is necessary, with consideration of the potential association between these conditions, including von Willebrand factor abnormalities, and the potential for aortic stenosis to exacerbate GAVE-related bleeding through high shear stress across the stenotic valve. Key considerations include:

• Careful risk assessment and management of cardiac complications.
• Multidisciplinary discussion involving cardiologists, surgeons, and anesthesiologists to determine the best course of management.
• Close monitoring of the patient's condition and adjustment of the treatment plan as needed.

From the Research

Management of GAVE Syndrome and Aortic Stenosis

To manage patients with Gastrointestinal Angiodysplasia (GAVE) syndrome and aortic stenosis, several factors need to be considered, including the severity of aortic stenosis, the presence of bleeding episodes, and the overall health of the patient.

• Aortic Valve Replacement: Aortic valve replacement seems to decrease the risk of gastrointestinal bleeding in patients with Heyde syndrome, which is similar to GAVE syndrome, and is curative in approximately 80% of patients 2.
• Type of Valve Replacement: Bioprosthetic valves are preferred over mechanical prostheses due to the lower risk of recurrent bleeding, with an overall risk of 15% compared to 50% with mechanical prostheses 2.
• Transcatheter Aortic Valve Implantation (TAVI): TAVI is a recommended therapy for specific subgroups of severe aortic stenosis patients, and its use has increased in recent years, with satisfactory 30-day clinical outcomes 3.
• Heart Valve Clinics: Multidisciplinary heart valve clinics can provide efficient management and outcome benefits for patients with moderate and asymptomatic severe aortic stenosis, including those with GAVE syndrome 4.
• Bleeding Risk: Patients with aortic valvular stenosis have an increased bleeding risk, and the mechanisms underlying this risk are complex, involving coagulopathy and other factors 5.
• Antithrombotic Therapy: After transcatheter aortic valve replacement, antithrombotic therapy should be carefully considered, with single-antiplatelet therapy and oral anticoagulation being reasonable strategies in patients without and with indications for concurrent anticoagulation, respectively 6.

Key Considerations

When managing patients with GAVE syndrome and aortic stenosis, it is essential to:

• Evaluate the severity of aortic stenosis and the presence of bleeding episodes
• Consider the type of valve replacement and the potential risks and benefits
• Involve a multidisciplinary team, including cardiologists, gastroenterologists, and surgeons, to provide comprehensive care
• Monitor patients closely for bleeding and thrombotic events, and adjust antithrombotic therapy as needed.