Upper Gastrointestinal Bleed Might Be Not the Most Common Source of Bleeding Among Patients With Left Ventricular Assist Device, a Nationwide Analysis

Abstract

Introduction: Prior small single center reports have shown that gastrointestinal bleeding (GIB) can occur in 18%-40% among left-ventricular assist devices (LVAD) recipients with upper GIB due to arteriovenous malformation (AVM) representing up to two thirds of cases. Our goal was to investigate the most common etiologies of GIB and the most commonly used endoscopic evaluation approach in this population using a nationwide database. Methods: Data was extracted from the Nationwide Inpatient Sample (NIS) database 2009-2011. Adult patients with discharge diagnosis International Classification of Diseases 9 (ICD9) codes of congestive heart failure and procedure code for LVAD, intra-aortic balloon pump (IABP) placement and orthotopic heart transplant (OHT) (comparison groups) were identified. Those who had more than one procedure during the same admission were excluded. A previously reported criteria was used to identify and classifying GIB with ICD9 codes in NIS as presented in the Table. GIB etiologies could overlap with the presence of more than one source. Endoscopic evaluation was classified into upper and lower GI endoscopy based on the presence of procedure ICD9 codes. Chi square test was used to compare the rates of upper versus lower GIB across the different cardiac procedures. Results: A total of 85,041 patients were included in the analysis with median age of 65 and 69% males and 64% Caucasians. The majority had IABP placement (75,744, 89%), followed by LVAD (4,869, 6%) and OHT (4,427, 5%). Patients who underwent LVAD placement had the highest GIB rate (8%), followed by IABP 5.8% then OHT 3% (p < 0.001). Both LVAD and OHT recipients had predominantly lower GIB in about 50% compared to 30% upper GIB. IABP recipients had even distribution of GIB source (p < 0.001). Upper GI endoscopy was the most commonly used evaluation in 40% as compared to lower GI endoscopy in 28% of LVAD recipients, Table. Conclusion: In this nationwide analysis, the percentage of lower GIB was higher than upper GIB among LVAD patient population, in the contrary to prior reports findings. However, the most commonly utilized diagnostic procedure was upper GI endoscope. Our findings indicate that both upper and lower GIB occurred at higher rate and the work up should be directed based on the clinical presentation bearing in mind that lower GIB could be as likely culprit as upper GIB.Figure 1