Small Bowel Endoscopy in End-Stage Heart Failure Patients With Obscure Gastrointestinal Bleeding After HeartMate II Implantation

Abstract

Introduction: The HeartMate II (HMII) axial continuous flow left ventricular assist device (LVAD) has been approved for end-stage heart failure (ESHF) patients as bridge-to-transplant (BTT) or destination therapy (DT) in recent years. However, a higher rate of post-implantation bleeding, including gastrointestinal bleeding, has been observed. The causes remain undetermined. Although upper and lower GI lesions in HMII patients were sparsely reported in small series recently, the occurrence of obscure GI bleeding (OGIB) and risk of a small bowel lesion have not been assessed. The best strategies for managing OGIB in HMII patients are still lacking. Methods: In a large U.S. academic heart and vascular institute, we used video small bowel capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) besides radiology to investigate OGIB in HMII patients. A total of 296 HMII LVADs were implanted in 280 patients from 2004 to 2013. OGIB was defined according to the AGA position statement. Patient characteristics, details of HMII implantation, perioperative data, and details of bleeding complications were prospectively collected in the institutional databases. Twenty-five patients who presented with OGIB after HMII implantation and underwent enteroscopy (CE and/or BAE) were recruited for the study. Clinical information including duration of HMII support prior to OGIB episode, medication use, lab data, and enteroscopic findings were analyzed. Results: Upon presentation of OGIB (25 patients, 8.9% of this cohort), the median duration of HMII support was 6.1 months. There were 21 men and 4 women with a mean (±sd) age of 60.1 (±13.2) years. The causes of ESHF were mostly related to ischemic (n=13) and dilated (n=10) cardiomyopathy. The most common co-morbidity was type 2 diabetes (DM) (n=13). The mean (±sd) body mass index (BMI) was 28.2 (±5.4) kg/m2. Eleven patients received HMII as DT, while 14 did as BTT. All patients received post-operative therapy including aspirin, dipyridamole, and warfarin with a goal INR of 1.7 to 2.5 and prophylactic use of a proton pump inhibitor. The enteroscopic investigation revealed angiodysplasias in jejunum and/or ileum in 9 patients, which were treated successfully by BAE with argon plasma coagulation, and medication-related erosions and/or ulceration in 8 patients. Four patients were diagnosed with anemia of undetermined source. Four patients had supratherapeutic INR related to warfarin use. The presence of angiodysplasias was unrelated to age, sex, type of ESHF, BMI, DM, BUN, Cr, pump thrombosis, DT, or BTT. There was no procedure-related complication. Conclusion: Our study reveals that angiodysplasia and medication-related small bowel bleed is a significant but manageable complication in HMII patients. CE and BAE are useful and safe in HMII patients.