Occult bleeding in left ventricular assist device recipients: It is the patient rather than the pump

Abstract

Authors have nothing to disclose with regard to commercial support. Authors have nothing to disclose with regard to commercial support. It was with great interest that we read the article by Grosman-Rimon and colleagues.1Grosman-Rimon L. Tumiati L.C. Fuks A. Jacobs I. Lalonde S.D. Cherney D.Z. et al.Increased cyclic guanosine monophosphate levels and continuous-flow left-ventricular assist devices: implications for gastrointestinal bleeding.J Thorac Cardiovasc Surg. 2016; 151: 219-227Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This is indeed a significant contribution to understanding mechanisms of occult bleeding in continuous-flow left ventricular assist device recipients. It is our opinion, however, that current research in this field focuses far too much on biochemical pathways and overlooks patient-related comorbidities at the time of the procedure. Real-life data from the Interagency Registry for Mechanically Assisted Circulatory Support registry2Jessup M.L. Goldstein D. Ascheim D.D. Teuteberg J.J. Park S.J. Naftel D.C. et al.Risk for bleeding after MCSD implant: an analysis of 2358 patients in INTERMACS.J Heart Lung Transplant. 2011; 30: S9Abstract Full Text Full Text PDF PubMed Google Scholar indicate that 1-year freedom from gastrointestinal bleeding is strongly associated with preoperative state (Interagency Registry for Mechanically Assisted Circulatory Support level, New York Heart Association functional class, age, need for dialysis, concomitant procedures, history of coronary artery bypass grafting), irrespective of pulsatile-flow or continuous-flow device operation. In addition, coagulation disorders predisposing toward bleeding after left ventricular assist device implantation, especially the loss of high–molecular weight von Willebrand factor multimers, seem to be detectable already before the procedure in patients with end-stage heart failure.3Ahamed J. Monteagudo J. Kinkhabwala M. Suarez-Farinas M. Garan A.R. Coller B.S. et al.Patients with end stage congestive heart failure have decreased high molecular weight Von Willebrand factor multimers and higher plasma levels of total TGF-β1: implantation of a left ventricular assist devices (LVAD) exacerbates both abnormalities.Blood. 2013; 122 ([abstract]): 1057Google Scholar In the light of these findings, it is important to identify patients at risk. It is our belief that we should focus on preimplantation patient profiles rather than on the pump. Increased cyclic guanosine monophosphate levels and continuous-flow left-ventricular assist devices: Implications for gastrointestinal bleedingThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 1PreviewWe examine the hypothesis that cyclic guanosine monophosphate (cGMP) levels are elevated in recipients of continuous-flow left ventricular assist devices (CF-LVADs) and that elevated cGMP levels are associated with a risk of gastrointestinal (GI) bleeding events. Full-Text PDF Open ArchiveElucidating the intricate mechanisms of gastrointestinal bleeding in a continuous-flow left ventricular assist device will lead to future therapeutic targetsThe Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 1PreviewWe are pleased that our study on cyclic guanosine monophosphate (cGMP) and gastrointestinal (GI) bleeding in recipients of a continuous-flow left ventricular assist device (CF-LVAD)1 gained interest by Spiliopoulos. Postoperative GI bleeding continues to be a major challenge for recipients of a CF-LVAD.2-4 We strongly agree with Spiliopoulos' comment that comorbidities at the time of surgery and factors related to the preoperative state such as INTERMACS level, New York Heart Association class, patients' age, history of coronary artery bypass grafting and dialysis should be carefully considered when selecting patients for CF-LVAD implantation. Full-Text PDF Open Archive