title: Characteristics of gastrointestinal bleeding after placement of continuous-flow left ventricular assist device: a case series.
abstract: BACKGROUND
  Medical management of patients with continuous-flow left ventricular assist devices (LVADs) remains challenging for the gastroenterologist given their high risk of gastrointestinal bleeding (GIB) and need for continuous anticoagulation.
  
  
  OBJECTIVE
  Our aim was to better characterize LVAD patients who presented with a GIB at our facility and delineate the prevalence, presentation, time to diagnosis, management, and therapeutic endoscopic interventions, including small bowel tools that may offer additional benefit.
  
  
  METHODS
  We retrospectively reviewed adult patients (>18 years) who underwent LVAD implantation at our tertiary care facility between October 2011 and October 2013. Electronic medical records were reviewed for presenting symptoms, average days to initial and repeat GIB, hospital course, and techniques that led to diagnosis and hemostasis.
  
  
  RESULTS
  Eighteen patients underwent LVAD implantation, of which 61 % presented with a GIB for a total of 20 presentations (1.8 per patient). Mean time to initial GIB was 154 days. Patients required an average of 1.8 endoscopic procedures per admission. Esophagogastroduodenoscopy (EGD) and push enteroscopy (PE) were more likely to lead to a diagnosis, and EGD was the most commonly used diagnostic tool at initial presentation. Sixty percent of patients who initially received EGD presented with a recurrent GIB and required PE, which was diagnostic and therapeutic for small bowel angiodysplasias in 80 % of cases.
  
  
  CONCLUSIONS
  We found a higher GIB rate compared with prior studies. Bleeding events were associated with multiple procedures and interventions. We recommend an algorithmic approach to LVAD patients who bleed. Our experience suggests that PE is warranted at initial presentation in order to achieve hemostasis, prevent recurrent GIB, and decrease subsequent readmission rates.
authors.affiliation: Department of Medicine, New York University School of Medicine, New York, NY, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Marsano
authors.forename: Jay
authors.initials: J
authors.lastname: Desai
authors.forename: Shannon
authors.initials: S
authors.lastname: Chang
authors.forename: Michelle
authors.initials: M
authors.lastname: Chau
authors.forename: Mark
authors.initials: M
authors.lastname: Pochapin
authors.forename: Grigoriy E
authors.initials: GE
authors.lastname: Gurvits
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors