Prevalence of Gastrointestinal Bleeding among Patients with Left Ventricular Assist Devices: A Systematic Review

Abstract

Purpose: Gastrointestinal bleeding (GIB) is increased in patients with left-ventricular assist devices (LVADs), likely due to increased formation of angiodysplastic lesions (AVMs) from an acquired von-Willebrand's deficiency. We performed a systematic review in order to assess the prevalence of GIB in patients with LVADs. Methods: A literature search was conducted using Pubmed and SCOPUS from 1990-2013 using the terms “left ventricular assist device,” “gastrointestinal bleeding,” “upper endoscopy,” “colonoscopy,” “capsule endoscopy,” and/or “deep enteroscopy.” Articles were included if they contained information regarding GIB in LVAD patients. We excluded case reports. Summary statistics were performed for the key variables of the included articles including mean age, gender, type of LVAD, usage of anticoagulation, presence of other co-morbid conditions, and mortality. Results: The literature search resulted in 229 articles. After exclusion of duplicates, case reports, and review articles, we included 15 papers. Table 1 demonstrates demographic features for LVAD patients with and without GIB. While there were no significant differences in age, gender, or race, patients with GIB were more likely to have continuous-flow LVADs, ischemic cardiomyopathy, and non-transplant status. History of prior GIB and chronic renal insufficiency were risk factors for subsequent bleeding. Aspirin, anti-platelet, oral anticoagulant, and proton pump inhibitor use were not significantly associated with bleeding. Table 2 demonstrates the prevalence of GIB, recurrence rates, and type of bleeding from the 13 studies where this data was available. GIB occurred in 223/1053 (23%) of continuous-flow LVAD patients with recurrence rates of 8%. Based on data from 8 papers, there were an average of 32 GIB episodes per study, or 0.4 per patient. Prevalence data was reported in 5 studies and included upper GIB in 49%, lower GIB in 26%, and mid-gut in 24%. AVMs were the cause of GIB in 40% based on 7 studies, and the mean time to bleeding was 86 days post-LVAD placement. Overall mortality was 24%, and was not higher in the GIB cohort.Table 1: Demographic features of LVAD patients with GIBTable 2: Characteristics of LVAD patients with gastrointestinal bleedingaConclusion: This systematic review demonstrated that GIB occurred in approximately one-quarter of patients receiving LVAD placement. The rate of GIB was much higher following continuous-flow as compared to pulsatile-flow LVAD placement. Non-transplant status, ischemic cardiac disease, history of GIB, and chronic kidney insufficiency were significantly associated with GIB. While nearly half of the patients had bleeding sources found in the upper GI tract, small bowel sources were detected in one quarter of the patients. AVMs were more common in the LVAD population compared to patients with GIB in the general population.