Mucosal Vascular Lesions Research Articles

Utility of combined use of elastography and von Willebrand factor antigen/thrombocyte ratio in prediction of gastroduodenal mucosal portal hypertension related vascular lesions

Background: Liver cirrhosis is the most important cause of portal hypertension, esophageal varices (EVs) represent its major complication as they may rupture and bleed with increased mortality rate. vWF-Ag is an established and valuable marker for determining the grade of fibrosis and cirrhosis and for mortality in patients with cirrhosis. Aim of our work is to search for the utility of combined use of elastography and Von Willebrand Factor Antigen/Thrombocyte Ratio in prediction of gastroduodenal portal hypertension related vascular lesions and identify suitable cutoff values for predicting these lesions. Patients and methods: 80 cirrhotic patients, were divided into 2 main groups, Group I included 20 patients with no evidence of portal hypertension related vascular lesions as verified by endoscopic examination (disease control group), group II, included patients with vascular lesions and was divided into 3 subgroups groups, group IIa included 20 patients with esophageal varices or gastro-esophageal varices, group IIb included 20 patients with isolated gastric varices, group IIc included 20 patients with portal hypertension related lesions other than esophageal and gastric varices.

Nd:YAG Laser Treatment of Massive Tongue Venous Malformation: A Case Report.

Venous malformations (VM) are slow-flow vascular lesions that result from morphogenesis errors. Composed of dysfunctional veins lacking smooth muscle cells, VMs grow slowly and may initially be managed by observation. Treatment is indicated for lesions that cause functional impairment. One treatment option is laser therapy, which is very effective due to its tissue penetration and relative selectivity. The Nd:YAG laser has been shown to treat small and moderately sized mucosal vascular lesions; in this case, it was applied in a staged approach for treatment of a massive venous malformation of the tongue. A 66-year-old male presented with a venous malformation involving the tongue and lower lip, the lesion estimated to be 10 x 14 x 15 cm in size. The Nd:YAG laser was used in three separate stages to photocoagulate the venous lesion. Follow-up for recurrence is ongoing, but currently shows complete malformation ablation with a 36.2% volume reduction after treatment. The Nd:YAG laser is an effective tool in the treatment of large vascular lesions. Successful laser application in a staged approach for the treatment of a venous malformation of this size and complexity further supports its clinical value. Monitoring for possible recurrence of the venous malformation should be ongoing.

The Efficacy of Argon Plasma Coagulation versus Carvedilol for Treatment of Portal Hypertensive Gastropathy

Background/Aim: Several treatment options have been developed for portal hypertensive gastropathy (PHG); medications and endoscopic management. The aim of this study was to evaluate the efficacy and safety of argon plasma coagulation (APC) versus Carvedilol in treatment of a cohort of Egyptian patients with severe PHG. Methods: A total of 130 patients with severe PHG were enrolled; 10 patients were excluded due to death and failure to complete the treatment sessions accordingly, 120 patients were included. Patients were divided into 2 groups: Group A (n = 52) treated with APC; Group B (n = 68) treated with oral Carvedilol. Success was defined as stabilization of hemoglobin (Hb) over 100 g/dL or Hb increase >10% from pretreatment level and reduction of blood transfusion requirements over the following 3 months after the start of therapy. Upper gastrointestinal endoscopy was performed to assess the degree and site of PHG. APC was conducted to areas with mucosal ectatic vascular lesions. Results: PHG was mostly fundic (36.35%) in APC group and (36.76%) in Carvedilol group (p = 0.56). Throughout follow-up period, there was significant increase in Hb level, serum iron, and serum ferritin with a significant decrease in total iron-binding capacity (TIBC) in APC group as compared to Carvedilol group (p < 0.001). Additionally, there was gradual increase in the mean Hb, serum iron, and serum ferritin and gradual decrease of TIBC in Carvedilol group. Accordingly, there was an overall improvement of iron deficiency anemia (IDA) in both groups; however, it was significantly better in APC group than in Carvedilol group. No major adverse events were detected in both the groups. Conclusion: APC significantly improves IDA and decreases transfusion requirements in patients with severe PHG as compared to oral Carvedilol with small risk of adverse events. Furthermore, the combination of APC and Carvedilol unless contraindicated could have a synergistic effect in controlling severe PHG.

Improvement of iron-deficiency anemia resulting from gastric antral vascular ectasia in patients with systemic sclerosis: cyclophosphamide versus argon plasma coagulation

BackgroundSystemic sclerosis is an autoimmune disease characterized by multisystem affection that could involve the gastrointestinal tract in the form of gastric antral vascular ectasia (GAVE) that might cause iron-deficiency anemia.ObjectiveEvaluation of the outcome and the experience of management of iron deficiency anemia resulting from GAVE in patients with scleroderma using cyclophosphamide therapy compared with argon plasma coagulation (APC).Patients and methodsThis study was conducted over a 2-year period from February 2015 to February 2017. Scleroderma patients with GAVE and iron deficiency anemia were treated with cyclophosphamide (group I) others with APC application to areas with mucosal vascular lesions (group II).ResultsIn total, 14 scleroderma patients with iron deficiency anemia resulting from associated GAVE were enrolled into two groups: group I included seven patients who were treated with cyclophosphamide infusion and group II were exposed to APC in sessions. Patients were followed up at 3 and 6 months; the endpoint was a complete response with improved anemia [hemoglobin (HB) and blood indices], and it was achieved in both groups as we found in group I patients there was a highly significant improvement (P<0.001) in HB, 3 and 6 months after therapy and in group II patients there was a highly significant improvement (P<0.001) in iron level 3 and 6 months, HB 6 months after. On comparing both groups it was clear that there was a significant improvement in group I as regards HB and ferritin levels 3 and 6 months after treatment when compared with group II, and highly significant increase in serum iron level 6 months after treatment in group I when compared with group II.ConclusionWe found that cyclophosphamide and APC are highly efficacious and safe in controlling anemia resulting from scleroderma-associated GAVE. Also, cyclophosphamide is more efficient than APC in improving in those patients.

Efficacy of argon plasma coagulation in the management of portal hypertensive gastropathy.

Objectives: Evaluation of the outcome and experience in 2 years of management of portal hypertensive gastropathy (PHG) by argon plasma coagulation (APC) in a cohort of Egyptian cirrhotic patients. Methods: This study was conducted over a 2-year period from January 2011 to February 2013. Upper gastrointestinal endoscopy was performed to evaluate the degree and site of PHG. APC was applied to areas with mucosal vascular lesions. Results: In total, 200 cirrhotic patients were enrolled; 12 patients were excluded due to death (n = 6) caused by hepatic encephalopathy (n = 3), hepatorenal syndrome (n = 2), or chronic lymphatic leukemia (n = 1), or did not complete the treatment sessions (n = 6), so 188 patients completed the study. PHG was mainly fundic in 73 patients (38.8 %), corporeal in 66 patients (35.1 %), and pangastric in 49 patients (26.1 %) (P = 0.026). Patients were exposed to APC and received proton pump inhibitors together with propranolol at a dose sufficient to reduce the heart rate by 25 % or down to 55 beats/min. The mean (± standard deviation) number of sessions was 1.65 ± 0.8; six patients needed four sessions (3.2 %), 19 patients needed three sessions (10.1 %), 74 patients needed two sessions (39.4 %), and 89 patients needed one session (47.3 %). Patients with fundic and corporeal PHG required the lowest number of sessions (P = 0.000). Patients were followed up every 2 months for up to 1 year; the end point was a complete response with improved anemia and blood transfusion requirement which was achieved after one session in 89 patients (75.4 %), two sessions in 24 patients (20.3 %) and three sessions in five patients (4.3 %). A complete response was more prevalent in patients with corporeal and fundic PHG (P = 0.04). Conclusions: After 2 years’ experience in managing PHG, we found that a combination of APC and non-selective beta blockers was highly efficacious and safe in controlling bleeding from PHG. In addition, APC alone is rapid, and effective in the control of PHG induced bleeding, especially when beta blockers are contraindicated.

Vascular targeted photodynamic therapy for bleeding gastrointestinal mucosal vascular lesions: A preliminary study

Vascular-targeted photodynamic therapy (V-PDT) has shown good selectivity and efficacy in the treatment of certain types of vascular disease, including port wine stains, age-related macular degeneration, and esophageal varices. This study was conducted to test the efficacy and safety of V-PDT in the treatment of gastrointestinal (GI) bleeding caused by the abnormal dilatation of capillaries. Patients with bleeding GI mucosal vascular lesions treated with V-PDT were included in this retrospective study. The efficiency of V-PDT was analyzed by comparing the documented endoscopy results, hemoglobin levels, and transfusion requirements before and at 6 months after the last V-PDT. Side effects during and after V-PDT and follow-up results were also analyzed. Seven patients with bleeding GI mucosal vascular lesions were treated with V-PDT. After 1-4 V-PDT sessions, all patients no longer needed transfusions to maintain a stable hemoglobin level during the follow-up period of 6 months. The mean hemoglobin level of the seven patients improved from 6.21±1.48 g/dl to 11.66±1.21 g/dl (p<0.001), and the GI bleeding and melena of all the patients disappeared. No perforations, strictures, scars, or episodes of photosensitization occurred in the seven patients, and there were no recurrences of GI bleeding during the 1-21 months of further follow-up. This preliminary study indicated that V-PDT is a highly selective, safe, well-tolerated, and effective treatment modality for bleeding GI mucosal vascular lesions. However, prospective studies with larger sample sizes are needed to confirm this finding.

Treatment of Mucosal Vascular Malformations With Variable-Pulse Neodymium:Yttrium-Aluminum-Garnet Laser

Background and objectivesTreatment of mucosal vascular lesions is a challenge for dermatologists, although various approaches have proven efficacy, including surgery, sclerotherapy, intralesional injection of corticosteroids, transfixion, and laser therapy. The aim of this study was to describe the results of treatment with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in 11 patients with venous malformations and varicosities. Patients and methodsWe describe the use of variable-pulse Nd:YAG to treat venous malformations or varicosities in the oral or genital mucosa of 8 women and 3 men seen in our hospital over a 1-year period. ResultsThe following laser parameters were used: wavelength, 1064nm; fluence, 100 to 200J/cm2; spot diameter, 3 to 5mm; and pulse duration, 30 to 65ms. The size of the lesions ranged from 5 to 30mm. In all cases, a clearance of 75% to 100% was achieved in a single session with excellent healing and no significant side effects. ConclusionsGiven its efficacy and ease of use, Nd:YAG may become a treatment of choice for mucosal vascular lesions. Comparative studies are now required to assess its potential superiority over other treatment options.

Tratamiento de malformaciones vasculares de mucosas con láser Nd:YAG de pulso variable

Background and objectives Treatment of mucosal vascular lesions is a challenge for dermatologists, although various approaches have proven efficacy, including surgery, sclerotherapy, intralesional injection of corticosteroids, transfixion, and laser therapy. The aim of this study was to describe the results of treatment with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in 11 patients with venous malformations and varicosities. Patients and methods We describe the use of variable-pulse Nd:YAG to treat venous malformations or varicosities in the oral or genital mucosa of 8 women and 3 men seen in our hospital over a 1-year period. Results The following laser parameters were used: wavelength, 1064 nm; fluence, 100 to 200 J/cm 2; spot diameter, 3 to 5 mm; and pulse duration, 30 to 65 ms. The size of the lesions ranged from 5 to 30 mm. In all cases, a clearance of 75% to 100% was achieved in a single session with excellent healing and no significant side effects. Conclusions Given its efficacy and ease of use, Nd:YAG may become a treatment of choice for mucosal vascular lesions. Comparative studies are now required to assess its potential superiority over other treatment options.

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Endoscopic cryotherapy for the treatment of bleeding mucosal vascular lesions of the GI tract: A pilot study

Background: Thermal therapy is the cornerstone of endoscopic treatment of bleeding mucosal lesions of the GI tract. However, there is a 20% failure rate and contact devices may be cumbersome in the treatment of large bleeding areas. A pilot study was conducted to evaluate the safety and efficacy of endoscopic cryotherapy for bleeding mucosal vascular lesions. Methods: Patients with recurrent bleeding from diffuse mucosal vascular lesions were treated with cryotherapy and had endoscopic and clinical follow-up. Results: Twenty-six patients with gastric and duodenal arteriovenous malformations (n = 7), watermelon stomach (n = 7), radiation-induced gastritis (n = 5), and radiation-induced proctitis (n = 7) were treated with mean of 3.4 (1.6) sessions. The best results were achieved in patients with radiation-induced proctitis, with cessation of bleeding in all 7 patients. Cryotherapy was also effective in patients with multiple arteriovenous malformations (86%) and watermelon stomach (71%). It was less effective in patients with radiation-induced damage to stomach and duodenum, although all patients in this group were debilitated because of disseminated malignancy. Conclusions: Cryotherapy is a safe and effective treatment for bleeding from diffuse mucosal lesions of the GI tract. Bleeding from radiation-induced proctitis and multiple arteriovenous malformations is particularly responsive to endoscopic cryotherapy.

The safety and efficacy of endoscopic cryotherapy for the treatment of bleeding mucosal vascular lesions

The safety and efficacy of endoscopic cryotherapy for the treatment of bleeding mucosal vascular lesions

3503 Endoscopic cryotherapy: results of a pilot study for the treatment of mucosal vascular lesions in humans.

Thermal therapy is the cornerstone of endoscopic treatment of mucosal disease of the gastrointestinal tract.We have recently described results of animal studies with a novel endoscopic device that delivers a freezing spray based on the Joules-Thompson effect (Gastrointes Endosc 1999;49:627-31). This device is simple, portable, inexpensive and uses compressed gas. We report the results of a pilot study using an improved version of the device to treat mucosal vascular lesions in humans. AIM: To determine the safety and efficacy of endoscopic cryotherapy to treat patients with mucosal vascular lesions and recurrent gastrointestinal bleeding. METHODS: Patients with recurrent GI bleeding from mucosal vascular lesions such as AVM's, watermelon stomach and radiation gastritis/proctitis who had failed conventional thermal therapy were recruited. Cryotherapy was applied to affected areas in sessions until all areas were treated. Follow-up endoscopy was performed 2-4 weeks after the final session in all patients. Serial hematocrits and blood transfusions requirements following therapy were recorded. RESULTS: 8 patients were recruited with gastric AVM's (n=5), watermelon stomach(n=1), radiation gastritis(n=1), radiation proctitis (n=1). There mean number of sessions for therapy was 3.25(mean range of 1-6 sessions). 6 patients had no further bleeding after a mean follow of 6.7±4.6 weeks. Follow-up endoscopy in these patients revealed normally regenerated mucosa. 2 patients continued to have bleeding despite cryotherapy, one had a watermelon stomach with refractory post-chemotherapy thromboctopenia and the second patient had radiation gastritis and maked debilitation from metastatic cancer. There were no complications noted in any of the 8 patients enrolled. CONCLUSIONS: This pilot study demonstrates that cryotherapy is safe and effective treatment for recurrent gastrointestinal bleeding from mucosal vascular lesions. Further controlled trials are needed.

Relationship of portal pressure and colorectal vasculopathy in patients with cirrhosis.

We studied the relationship between portal pressure and colorectal mucosal vascular lesions in cirrhotics and the effectiveness of drug therapy in treating these lesions. Colonoscopy and hepatic venous pressure gradient (HVPG) studies were performed in 21 cirrhotics. Oral spironolactone plus transdermal nitroglycerin were given to patients who had diffuse mucosal cherry-red spots and/or rectal varices. The colonoscopy and HVPG determinations were repeated after four weeks. Colonoscopic findings included vascular ectasias in 13 patients (62%), diffuse cherry-red spots in the rectum in five patients (24%), and rectal varices in eight patients (38%). Overall, colorectal mucosal vascular lesions were found in 16 cirrhotics (76%). These findings were not found in 21 age- and sex-matched noncirrhotic controls. Vascular ectasias appeared without relationship to the HVPG. Patients with diffuse cherry-red spots (N = 5, 22.4+/-3.4 mm Hg) had a significantly higher HVPG than those without (N = 16, 16.6+/-3.3 mm Hg, P < 0.01). However, no significant difference was found in HVPG between patients with rectal varices (N = 8, 19.4+/-4.6 mm Hg) and patients without rectal varices (N = 13, 17.2+/-3.8 mm Hg). After four weeks of drug therapy, diffuse cherry-red spots became less obvious when the HVPG decreased more than 20%. Rectal varices did not change their appearance with HVPG reduction. We found that colorectal vascular lesions are common in cirrhotics. Diffuse cherry-red spots are probably dependent on elevated portal pressure, but vascular ectasias and rectal varices are not related to the degree of portal pressure. Chronic drug therapy with reduction of portal pressure improves colonoscopic findings such as diffuse cherry-red spots.

Alterations in colonic mucosal vessels in patients with cirrhosis and noncirrhotic portal hypertension

Changes in intestinal mucosal microvasculature as a cause of lower gastrointestinal hemorrhage in patients with portal hypertension have been well documented clinically, but the analogous histomor phological changes have not been well characterized. The goal of this study was to evaluate qualitative and quantitative changes in colonic mucosal vessels in patients with cirrhosis or clinically evident portal hypertension and to correlate these changes with endoscopic and clinical findings. Colon biopsy or resection specimen slides from 46 patients with biopsy-proven cirrhosis (44 patients) or noncirrhotic portal hypertension (two patients) were reviewed. Immnunoperoxidase stain for CD34 antigen was used to facilitate visualization of mucosal vessels, and vessel diameter was measured with a micrometer. Patients with inflammatory bowel disease were excluded. Twenty-four normal colon biopsy specimens served as controls. Mucosal vessels were divided into superficial, intermediate, and deep layers. As a group, the cirrhotic patients had a significantly higher mean diameter of vessels in all three layers. Qualitatively, increased numbers of small vessels and prominent branching were noted, especially in the superficial and intermediate layers. Tortuous, thick-walled vessels, suggesting arterialization of venules, were present in some cases. Eleven patients had endoscopic findings suggestive of vascular abnormalities, including erythematous mucosal patches, red macules, and telangiectasias. Eighteen had esophageal varices, and five had portal gastropathy. Nineteen patients had gastrointestinal (GI) bleeding, localized to the lower GI tract in 11. These qualitative and quantitative findings suggest that colonic mucosal vascular lesions are common in portal hypertension and may represent a potential source of clinically significant lower GI hemorrhage in these patients.

Radiation-induced jejunal mucosal vascular lesions as a cause of significant gastroinstestinal hemorrhage

Radiation-induced jejunal mucosal vascular lesions as a cause of significant gastroinstestinal hemorrhage

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon.

Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions. To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon. We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months. After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred. Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective.

Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy.

Hematochezia from mucosal vascular lesions usually confined to the rectum represents an uncommon but problematic late complication of pelvic radiotherapy. We studied 47 patients with medically refractory hematochezia resulting from radiation-induced rectosigmoid mucosal vascular lesions. All lesions were endoscopically coagulated with Nd:YAG laser. Median duration of hematochezia before laser therapy was 11 months, despite previous medical treatment (98%) or bypass colostomy (6%). Within 3 to 6 months after laser treatment, the number of patients with daily hematochezia fell from 40 (85%) to 5 (11%; p < 0.001), and the median hemoglobin level increased from 9.7 gm/dl to 11.7 gm/dl (p < 0.001). Complications occurred in three patients (6%); no deaths occurred. The condition in six patients (12.8%) was not improved by laser treatment. Two patients (4%) ultimately required surgical treatment for bleeding control. On the basis of symptomatic, hematologic, and endoscopic responses, Nd:YAG laser photocoagulation controlled bleeding from radiation proctopathy in most patients with an acceptably low morbidity. Patients with sigmoid colon involvement responded less favorably. Endoscopic laser photocoagulation should be considered before surgical intervention for treatment of hematochezia from radiation proctopathy.

Vascular Malformations of the Gastrointestinal Tract

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.

Endoscopic laser surgery in the colon and rectum.

The first applications of laser energy in the gastrointestinal tract occurred barely a decade ago. Since then, endoscopic laser therapy has become widespread in the management of colonic and rectal disease. Applications have been developed for the palliative therapy of obstructing or bleeding malignancies, for the management of some benign and premalignant mucosal diseases and for certain anatomic problems such as anastomotic strictures. Recurrent bleeding from mucosal vascular lesions can be controlled with laser therapy. Methods for treating anorectal disorders also are evolving. The continuing development of new endoscopic systems for increasing ease of access to the gastrointestinal tract all point to ever-increasing applications for laser therapy in colonic and rectal surgery.

The syndrome of calcific aortic stenosis and gastrointestinal bleeding: Resolution following aortic valve replacement

A syndrome exists in elderly patients of gastrointestinal tract bleeding (GIB) associated with calcific aortic stenosis (CAS). The bleeding, which may be chronic and massive, has been attributed to tiny mucosal vascular lesions which usually occur in the right colon. Selective mesenteric angiography is the best way to demonstrate the lesions, which are not seen on barium examination and may not been seen endoscopically. Previously, the recommended treatment has been segmental bowel resection, usually right hemicolectomy. Three patients have been seen with this syndrome of CAS-GIB. All three patients had severe CAS and chronic GIB and two of them had had previous, unsuccessful, intestinal operations for their GIB. All three patients had aortic valve replacement and the GIB stopped in all three patients after valve replacement. Possible mechanisms are discussed. It is concluded that aortic valve replacement is the treatment of choice for the syndrome of CAS-GIB.