title: Pre-Operative Right Ventricular Dysfunction Is Associated With Gastrointestinal Bleeding in Patients Supported With Continuous-Flow Left Ventricular Assist Devices.
abstract: OBJECTIVE
  This study sought to determine whether severe right ventricular (RV) dysfunction in the pre-operative setting is associated with an increased risk of gastrointestinal bleeding (GIB) post-left ventricular assist device (LVAD).
  
  
  BACKGROUND
  GIB is a significant complication in patients supported with continuous-flow LVADs. The impact of RV dysfunction on the risk of GIB has not been investigated.
  
  
  METHODS
  We retrospectively identified 212 patients who survived index hospitalization after implantation of HeartMate II (Thoratec Corp., Pleasanton, California) or Heartware HVAD (HeartWare Corp., Framingham, Massachusetts) from June 2009 to April 2013. Patients with severe RV dysfunction on pre-LVAD echocardiogram (n = 37) were compared to patients without severe RV dysfunction (n = 175). The primary outcome was freedom from GIB.
  
  
  RESULTS
  The majority of patients were male (79%) with a median INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of 2 at LVAD implantation. There were no significant differences between cohorts with respect to demographics, comorbidities, device type, international normalization ratio, or aspirin strategy. During follow-up, 81 patients had GIB events: 23 of 37 (62%) in the severe RV dysfunction group versus 58 of 175 (33%) in the control group (p = 0.001). After adjustment for age and ischemic cardiomyopathy, severe RV dysfunction was associated with increased risk of GIB (hazard ratio: 1.799, 95% confidence interval: 1.089 to 2.973, p = 0.022).
  
  
  CONCLUSIONS
  In this single-center sample of patients supported with continuous-flow LVADs, severe RV dysfunction on pre-LVAD echocardiogram was associated with an increased risk of GIB. Further studies are needed to investigate possible mechanisms by which RV dysfunction increases the risk of GIB and to identify patient populations who may benefit from alterations in antithrombotic strategies.
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Sparrow
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Nassif
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: David S
authors.initials: DS
authors.lastname: Raymer
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Eric
authors.initials: E
authors.lastname: Novak
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Shane J
authors.initials: SJ
authors.lastname: LaRue
authors.affiliation: Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri. Electronic address: jschilli@dom.wustl.edu.
authors.forename: Joel D
authors.initials: JD
authors.lastname: Schilling
mesh_terms: D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000150:complications*; D006333:Heart Failure / Q000601:surgery*; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000150:complications*; D057234:Preoperative Period; D011379:Prognosis; D012042:Registries; D012189:Retrospective Studies; D012720:Severity of Illness Index; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology
keywords: gastrointestinal bleed; heart failure; left ventricular assist device; right ventricular dysfunction