Promising Novel Treatment with Intravenous Bevacizumab for Refractory Gastrointestinal Bleeding from Angiodysplastic Lesions in Patients Supported with a Continuous-Flow Left Ventricular Assist Device: A Pilot Study

Abstract

Purpose Vascular endothelial growth factor (VEGF) has been implicated in gastrointestinal angiodysplasias (GIADs). Bevacizumab (Avastin) is a humanized monoclonal antibody against VEGF and confers potent antiangiogenic properties. We sought to examine the safety and efficacy of intravenous bevacizumab in a small group of LVAD patients with refractory GI bleeding due to GIADs. Methods We conducted a pilot study between January, 2017 and March, 2018 at a large institution to examine the efficacy and safety of intravenous bevacizumab administration in patients supported with continuous flow LVAD who presented with refractory GIADs-related bleeding, defined as endoscopy-proven GIADs that failed both conventional medical and endoscopic therapies. We assessed response to therapy based on changes in number of GI bleeding hospitalizations, blood transfusions, and scoping procedures. Results Five LVAD patients (mean age 67 years, all male, all HeartMate II) with refractory GIADs-associated bleeding were treated with intravenous bevacizumab for a total of 8 cycles according to our institutional protocol. The median (interquartile range [IQR]) of follow up while on LVAD was 11.0 (2.6, 25.5) and 11.2 (10.2, 13.5) months pre and post bevacizumab initiation, respectively. Intravenous bevacizumab administration resulted in a remarkable decrease in the annual number of blood transfusions (45.8 [13.6, 133.8] vs. 6.0 [3.7, 12.2]), hospitalizations for GI bleeding (5.6 [3.1, 11.7] vs. 1.7 [0.40, 2.8]), and scoping interventions (10.6 [4.7, 41.7] vs. 2.3 [0, 5.1]) (Figure). All patients tolerated bevacizumab therapy without serious side effects. Conclusion Intravenous bevacizumab is an effective and safe treatment option for LVAD patients with refractory GI bleeding due to GIADs. Further studies are warranted to examine its long-term efficacy and safety in a large LVAD population.