From the Guidelines
Management of a left ventricular assist device (LVAD) patient with a gastrointestinal (GI) bleed requires immediate medical attention and careful anticoagulation management, with a focus on stabilizing the patient, identifying and treating the bleeding source, and reintroducing anticoagulation therapy as needed, as recommended by the most recent guidelines 1. The initial step in managing an LVAD patient with a GI bleed involves stabilizing the patient with fluid resuscitation and blood products as needed.
- Temporarily holding anticoagulation therapy, including warfarin and antiplatelet agents, until bleeding is controlled is crucial, as anticoagulants can exacerbate bleeding, and their management is critical in patients with GI bleeding, as noted in a study published in Gut in 2021 1.
- Performing urgent endoscopy to identify and treat the bleeding source, which is often arteriovenous malformations due to acquired von Willebrand syndrome in LVAD patients, is essential for controlling the bleeding.
- Consideration of octreotide (50-100 mcg subcutaneously or IV every 8 hours) to reduce splanchnic blood flow and help control bleeding may be beneficial, although the evidence for its use in this context is limited. Once the patient is hemodynamically stable with no active bleeding for 48-72 hours, gradually reintroducing anticoagulation, starting with a reduced INR target of 1.5-2.0 before slowly returning to the standard LVAD target of 2.0-3.0, is recommended, as suggested by the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guideline update in 2021 1. Throughout this process, maintaining close coordination between cardiology and gastroenterology teams is vital to ensure optimal management of the patient's condition. The high shear stress created by the LVAD impeller contributes to acquired von Willebrand factor deficiency and platelet dysfunction, explaining the increased bleeding risk in these patients, as noted in a study published in the Journal of Thoracic and Cardiovascular Surgery in 2009 1. For recurrent bleeding episodes, considering long-term reduction in anticoagulation targets or device speed adjustment if hemodynamically tolerable, as recommended by the American Heart Association in 2017 1, may be necessary to minimize the risk of further bleeding.
From the Research
Management Options for LVAD Patients with GI Bleeding
The management of gastrointestinal (GI) bleeding in patients with Left Ventricular Assist Devices (LVADs) involves several strategies, including:
- Ensuring hemodynamic stability 2
- Holding or reversing antithrombotic therapy 2
- Investigating and controlling the source of GI bleeding through diagnostic and interventional endoscopic and radiologic means 2, 3
- Using prophylactic medication, such as danazol, octreotide, and bevacizumab, to decrease the risk of GI bleeding 2
- Implementing an endoscopic algorithm that emphasizes upfront evaluation of the small bowel and minimizes low-yield procedures 3
Endoscopic Management
Endoscopy remains the standard of care for diagnosing and managing GI bleeding in LVAD patients, with upper endoscopy offering the highest diagnostic yield 4, 3. The effectiveness of endoscopic hemostasis in this population is not well established, but studies have shown that endoscopic management can be effective in reducing low-yield procedures, improving diagnostic and therapeutic yield, and decreasing healthcare resource utilization and costs 3.
Medical Management
Medical therapy, including alterations in LVAD settings, has been evaluated as a means of preventing or treating GI bleeding, with variable results 4, 5. The use of medication, such as antithrombotic therapy, must be carefully managed to balance the risk of GI bleeding with the risk of thromboembolic events 6.
Risk of Thromboembolic Events
Patients who experience GI bleeding are at a higher risk for subsequent thromboembolic events, suggesting that reduction in anti-coagulation and anti-platelet management to treat GI bleeds may contribute to this risk 6. Therefore, careful management of antithrombotic therapy is crucial in LVAD patients with GI bleeding.