Intractable Gastrointestinal Bleeding Events After Left Ventricular Assist Device Implantation

Abstract

<h3>Introduction</h3> There is evidence that continuous-flow left ventricular assist device (CF-LVAD) support may cause gastrointestinal (GI) angiodysplasias. Bleeding events are the most common complications after LVAD implantation emphasizing the importance of GI bleeding management. <h3>Case Report</h3> A 63-year-old male patient underwent CF-LVAD implantation for advanced heart failure in 2014. Anticoagulation consisted of warfarin with a target INR of 2.0 to 3.0 and acetylsalicylic acid (ASA) 100 mg o.d. Recurrent anemia, managed by transfusions of over 500 units of packed red blood cells and iron supplementation, has been of major concern since 2014. Gastroscopy and colonoscopy were negative. Capsule endoscopy revealed jejunal angioectasias and ileal angiodysplasias. ASA was cessated, warfarin was temporarily stopped and INR was lowered to 1.8. Octreotide and erythropoietin were initiated. Hydrocortisone suppository was added and ligation for haemorrhoids was performed for rectal bleeding. As anaemia deteriorated, warfarin was permanently stopped in 2018; thus, patient has been maintained without anticoagulation for 3 years. LVAD pump speed was reduced to increase pulsatility. As computed tomography presumed jejunal bleeding, small bowel resection was performed. Angiodysplasia was histologically confirmed and off-label therapy was initiated with thalidomide and bevacizumab. Diffuse angiodysplasias of the colon and ileum were treated by argon plasma coagulation. Aminocaproic acid and tranexamic acid were administered. Meanwhile, LVAD pump speed was increased due to worsening of heart failure. Patient has experienced several self-terminating pump-stops since 2020, suspected to be caused by damaged insulation of the driveline. Due to his poor overall condition and unability to tolerate any forms of anticoagulation, neither heart transplantation, nor pump replacement could be performed. The patient died of LVAD stoppage in 2021. Pump thrombosis was excluded on autopsy. The breaches in the wire insulation causing pump-stops were confirmed by factory investigation. <h3>Summary</h3> In case of GI bleeding, hemostasis and LVAD pump management are crucial as the management of anticoagulation should balance between bleeding and risk for thromboembolism. Reduction in bleeding events emphasizes the importance of experimental therapies in case of intractable bleeding events.