Resolution of Recurrent Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement in a Patient with Heydeʼs Syndrome

Abstract

Purpose: Bleeding from gastrointestinal angiodysplasia (GA) in patients with aortic stenosis (AS) has been recognized for several decades. Aortic valve replacement (AVR) in patients with symptomatic AS is associated with favorable outcomes and is recommended in recurrent GA related gastrointestinal bleeding (GIB), especially when associated with symptomatic AS. Treatment options are limited for patients who are poor surgical candidates. It is this subset of patients that might benefit the most from a minimally invasive treatment of AS. We present a case of Heyde's syndrome in a poor surgical candidate who was treated with Transcatheter Aortic Valve Replacement (TAVR) for symptomatic severe calcific AS and experienced complete resolution of recurrent GIB. An 86 year old male with a past medical history of recurrent syncope, multiple episodes of AVM-associated intestinal blood loss, Hodgkin's lymphoma, and prostate cancer was evaluated for syncope. Physical exam revealed a harsh, late peaking crescendo-decrescendo murmur best heard in the aortic area. Laboratory values revealed a microcytic anemia but were otherwise unremarkable. An echocardiogram obtained soon thereafter was consistent with severe calcific AS with a calculated valvular area of 0.7 cm square and a transvalvular gradient of 56 mmHg. The patient developed a lower GI bleed while in the hospital. A colonoscopy revealed multiple bleeding AVM's with successful hemostasis. Considering the high risk for invasive surgery, a decision was made to proceed with a TAVR. The patient has not had any further episodes of gastrointestinal bleeding since his discharge form the hospital. The association of AS and bleeding from GA was first postulated by Heyde in 1958. Since then, there have been numerous cases reported in medical literature worldwide. There is evidence that suggests a functional vWF deficiency as a precipitating cause of GA associated bleeding. AVR appears to offer the best results for long term resolution of AS related GIB. With the increasing prevalence of AI and AS with age, it is likely that there will be an increasing number of patients with Heyde's syndrome who are poor surgical candidates. Moving forward, it is conceivable that minimally invasive procedures like TAVR might be of significant benefit in this patient population. TAVR was recently approved for the treatment of severe symptomatic calcific AS in patients that are poor surgical candidates. Thus far, there has been only one other report of a patient with suspected Heyde's syndrome benefiting from TAVR. As our case demonstrates, this option should be strongly considered to ameliorate recurrent GI bleeding in patients with AS who are not surgical candidates.