title: The Diagnostic Yield of Repeated Endoscopic Evaluation in Patients with Gastrointestinal Bleeding and Left Ventricular Assist Devices.
abstract: Left ventricular assist devices (LVADs) are increasingly common in patients with advanced heart failure. GI bleeding (GIB) occurs in 20-30 % of these patients and can arise anywhere in the GI tract. Given the high rates of GIB in this population, our aim was to determine the diagnostic yield of repeated endoscopic evaluation in these patients.
  
  
  
  We performed a retrospective review of all 257 patients who had LVADs placed between 2008 and 2013 at Duke University Hospital and identified all patients who underwent any endoscopic evaluation for GIB.
  
  
  
  Of the 257 patients with LVADs placed, 78 (30 %) underwent at least one endoscopy for GIB. A source was identified in 36 % of cases, most commonly angioectasias (53.6 %). Treatment was performed in 67.9 % of patients and hemostasis was achieved in all. 64.1 % of the cohort underwent a second endoscopy for GIB. 42.9 % of these exams revealed a bleeding source. Endoscopic treatment was employed in 76.2 %. 38.5 % of the cohort underwent a third endoscopic exam for bleeding and a source was identified in 53.3 % with angioectasias remaining most common (56.3 %). By Fisher's exact and Chi-square testing, only the presence of a bleeding source (p = 0.0034) and use of hemostatic therapy (p = 0.0127) on the index examination were significantly associated with re-bleeding.
  
  
  
  GIB is common in patients with LVADs. The diagnostic and therapeutic yield of endoscopy is remains high with repeated interventions. Despite these high yields, a large portion of the cohort requires repeated interventions for recurrent bleeding.
authors.affiliation: Division of Gastroenterology, Duke University Hospital, Box 3913, Durham, NC, 27701, USA. Hassan.dakik@duke.edu.
authors.forename: Hassan K
authors.identifier: 0000-0002-5506-2909
authors.initials: HK
authors.lastname: Dakik
authors.affiliation: Division of Gastroenterology, Duke University Hospital, Box 3913, Durham, NC, 27701, USA.
authors.forename: Alyson A
authors.initials: AA
authors.lastname: McGhan
authors.affiliation: Division of Biostatistics, Duke University Hospital, Durham, NC, USA.
authors.forename: Shih-Ting
authors.initials: ST
authors.lastname: Chiu
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, NC, USA.
authors.forename: Chetan B
authors.initials: CB
authors.lastname: Patel
authors.affiliation: Division of Cardiothoracic Surgery, Duke University Hospital, Durham, NC, USA.
authors.forename: Carmelo A
authors.initials: CA
authors.lastname: Milano
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, NC, USA.
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Rogers
authors.affiliation: Division of Biostatistics, Duke University Hospital, Durham, NC, USA.
authors.forename: Shein-Chung
authors.initials: SC
authors.lastname: Chow
authors.affiliation: Division of Gastroenterology, Duke University Hospital, Box 3913, Durham, NC, 27701, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Wild
mesh_terms: D016099:Endoscopy, Gastrointestinal; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000473:pathology*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018487:Ventricular Dysfunction, Left / Q000628:therapy
keywords: Angioectasia; GI bleeding; Left ventricular assist devices; Therapeutic endoscopy
references.citation: J Heart Lung Transplant. 2013 Feb;32(2):141-56
references.pmid: 23352390
references.citation: J Heart Lung Transplant. 2005 Jan;24(1):105-9
references.pmid: 15653390
references.citation: N Engl J Med. 2014 Jan 2;370(1):33-40
references.pmid: 24283197
references.citation: J Thorac Cardiovasc Surg. 2009 Jan;137(1):208-15
references.pmid: 19154927
references.citation: Ann Thorac Surg. 2010 Oct;90(4):1263-9; discussion 1269
references.pmid: 20868825
references.citation: Blood. 1994 Apr 15;83(8):2171-9
references.pmid: 8161783
references.citation: Eur J Cardiothorac Surg. 2012 Aug;42(2):319-23; discussion 323
references.pmid: 22398471
references.citation: Gastrointest Endosc. 2012 May;75(5):973-9
references.pmid: 22341716
references.citation: Clin Cardiol. 2013 Apr;36(4):190-200
references.pmid: 23378047
references.citation: J Heart Lung Transplant. 2014 Jan;33(1):60-4
references.pmid: 24021944
references.citation: Clin Gastroenterol Hepatol. 2014 Sep;12(9):1461-7
references.pmid: 24480675
references.citation: J Heart Lung Transplant. 2009 Sep;28(9):881-7
references.pmid: 19716039
references.citation: Circ Heart Fail. 2011 Nov;4(6):779-84
references.pmid: 22086831
references.citation: J Heart Lung Transplant. 2014 Jan;33(1):23-34
references.pmid: 24418731
references.citation: Circ Heart Fail. 2010 Nov;3(6):675-81
references.pmid: 20739614
references.citation: Gastroenterology. 2007 Nov;133(5):1694-6
references.pmid: 17983811
references.citation: Clin Gastroenterol Hepatol. 2015 Jan;13(1):107-14.e1
references.pmid: 24858705
references.citation: Ann Thorac Surg. 2012 May;93(5):1534-40
references.pmid: 22541185