Management of Left Ventricular Assist Device (LVAD)-Related Gastrointestinal Bleeding (GIB): A Retrospective Case Series: Presidential Poster

Abstract

Introduction: GIB complicates 17-30% of postoperative LVAD placements. Despite attempts to modulate anticoagulation and prescreening to prevent bleeding, there is no consensus on treatment for these patients. Our objective is to evaluate the potential role of octreotide LAR in patients with an LVAD for secondary prevention of GIB. Methods: Forty patients underwent LVAD implantation at our institution between 12/2012 and 12/2014. Ten developed GIB during their postoperative course (25%). Eight had bleeding secondary to arteriovenous malformations (AVMs) in the small bowel and two secondary to ulcers. Four patients suffered a recurrent GIB which was not controlled by endoscopy and were placed on octreotide. Three of the four were placed on octreotide LAR. We evaluated the clinical scenarios of these patients. Results: Three patients (2 men and 1 woman; ages 60-72) received octreotide LAR. None had a GIB prior to LVAD implantation. Post implantation, patients had a median of 5 endoscopic procedures for GIB prior to starting octreotide(range 2-9). AVMs were the cause of GIB in all 3 cases. The first patient had 7 GIBs with 36 units of packed red blood cells (pRBCs) transfused over the course of 12 months. After octreotide was started, she had 3 GIBs with 16 units of pRBCs transfused over the following 16 months. One GIB was after a missed octreotide dose and required 8 of the 16 units of pRBC. The second patient had 4 GIBs with 32 units of pRBCs transfused over 2 months. After octreotide he had 2 GIBs requiring 8 units of pRBCs over 6 months. The third patient had 2 GIBs with 33 units of pRBC transfused over 11 months. After octreotide he had no further GIBs and no transfusions for 12 months. Overall, these patients required a median of 2 endoscopic procedures (range 0-3) and a median of 8 units pRBCs (0-16) after octreotide LAR was started. In the two patients with GIBs despite octreotide, dosing was increased to twice monthly with no further bleeding. There were no thrombotic events after starting octreotide. Discussion: In post-LVAD patients, octreotide appears to markedly decrease the frequency of GIB with a reduction in transfusion requirements and endoscopic procedures. Octreotide reduces mesenteric blood flow and portal venous pressure, and has been used for treatment of small bowel AVMs with an excellent safety profile. Octreotide may be an effective therapy for secondary prevention of GIB in patients with an LVAD and warrants further prospective investigation.Table 43: Summary of Findings