#CardioTwitter #CardioNerds #GITwitter How do you approach GI Bleed in patients with LVAD, we'll follow a patient from presentation to discharge
72 Y/F s/p LVAD 1 year ago presented with in
72 Y/F s/p LVAD 1 year ago presented with in
Learning objectives
Identification GIB in a patient with LVAD
Predictive factors for LVAD and GIB
Diagnosis and management approach of GIB & LVAD
Primary and Secondary prevention of recurrent GIB
Identification GIB in a patient with LVAD
Predictive factors for LVAD and GIB
Diagnosis and management approach of GIB & LVAD
Primary and Secondary prevention of recurrent GIB
Patient-reported dizziness and blood in for the last 1 month
Lab work revealed a drop in Hb from 8 to 6 (3 months ago), INR has been therapeutic since LVAD implant.
So what do we do next?
Lab work revealed a drop in Hb from 8 to 6 (3 months ago), INR has been therapeutic since LVAD implant.
So what do we do next?
First off, what defines GIB in LVAD patients
Any clinically suspected or documented bleeding from the GI tract, which can be indicated by new drop-in hgb and/or the appearance of melena, hematochezia, hematemesis, or guaiac-positive
#GITwitter #CardioTwitter
Any clinically suspected or documented bleeding from the GI tract, which can be indicated by new drop-in hgb and/or the appearance of melena, hematochezia, hematemesis, or guaiac-positive
#GITwitter #CardioTwitter
The incidence of GIB varies, some reports indicate 15-40% in CF-LVAD patients
The most common etiology is AVM from 21% to 61%.
https://bit.ly/32sPo3e
The most common etiology is AVM from 21% to 61%.
https://bit.ly/32sPo3e
The etiology and pathophysiology of #GIB in LVAD patients could be multifactorial as follows:
One study looked at a predictive model for LVAD and GIB: the Utah Bleeding Risk Score(UBRS) based on preimplant factors based on 351 LVAD recipients
Patients were stratified based on UBRS:
Low : 0-1
Intermediate: 2-4
High: 5-9
Patients were stratified based on UBRS:
Low : 0-1
Intermediate: 2-4
High: 5-9
Back to , after acute stabilization:
Transfusing to Hb > 7, stop a/c
EGD +/- Colo No Lesion
The following can be considered:
Capsule Endoscopy? Angio? Tagged RBC Scan, intra-op enteroscopy?
See the Algorithms below for Active/Overt Bleeds
Transfusing to Hb > 7, stop a/c
EGD +/- Colo No Lesion
The following can be considered:
Capsule Endoscopy? Angio? Tagged RBC Scan, intra-op enteroscopy?
See the Algorithms below for Active/Overt Bleeds
But what if the source is still hidden?
Algorithm for Obscure Occult Bleeding.
What is your institution's endoscopic algorithm for GIB in CF-LVAD patients? Leave in the comments below!
Back to
(Important considerations – a/c reversal, VAD speed adjustments if needed)
Algorithm for Obscure Occult Bleeding.
What is your institution's endoscopic algorithm for GIB in CF-LVAD patients? Leave in the comments below!
Back to
(Important considerations – a/c reversal, VAD speed adjustments if needed)
In terms of preventive strategies: ACEi/ARB, Digoxin, Omega-3-Fatty acids have all been retrospectively studied.
Our group performed network meta-analysis comparing these 3 meds, found Omega-3-FA is beneficial in primary prevention.
https://bit.ly/3svQmq0
#GIB #CardioTwitter
Our group performed network meta-analysis comparing these 3 meds, found Omega-3-FA is beneficial in primary prevention.
https://bit.ly/3svQmq0
#GIB #CardioTwitter
Our patient had an extensive w/up for Obscure overt bleeding with no identifiable etiology. After 5 days, the patient Hb continued to drop but remained stable and we focused on preventive strategies.
The following is one a/c strategy in CF-LVAD and recurrent GIB
#GITwitter
The following is one a/c strategy in CF-LVAD and recurrent GIB
#GITwitter
A secondary prevention strategy for GIB in LVAD
Danazol, Octreotide, Thalidomide Tamoxifen, Bevacizumab have been studied in retrospective studies.
Thalidomide may prevent GIB better than Danazol & Octreotide.
Be cautious with the side-effect profile of these meds.
Danazol, Octreotide, Thalidomide Tamoxifen, Bevacizumab have been studied in retrospective studies.
Thalidomide may prevent GIB better than Danazol & Octreotide.
Be cautious with the side-effect profile of these meds.
The proposed mechanism for these medications are as follows:
Thanks to @WaqasTahir for this incredible design of pathophysiology.
Thanks to @WaqasTahir for this incredible design of pathophysiology.
Bevacizumab and Tamoxifen have also be used in 2dry prevention and have shown to be beneficial but not included in our analysis.
https://bit.ly/3dzZsOj
https://bit.ly/32wRNdo
However, be cautious with the side-effect profile of these drugs
https://bit.ly/3dzZsOj
https://bit.ly/32wRNdo
However, be cautious with the side-effect profile of these drugs
Our patient was started on Omega-3-FA and IV Octreotide.
After 5 days, Hgb stabilized.
Discharged on Danazol & Omega-3-FA, stopped aspirin on discharge, resumed on coumadin
...and VIOLA!! no new episodes of GIB over 6 months!
After 5 days, Hgb stabilized.
Discharged on Danazol & Omega-3-FA, stopped aspirin on discharge, resumed on coumadin
...and VIOLA!! no new episodes of GIB over 6 months!
Summary -1
AVMs are comon cause of GIB in LVAD
UBRS can be used to predict GIB in LVAD recipients
Transfusing to Hb > 7 and for significant bleeds holding a/c and lets say melena: EGD +/- Colo No Lesion?
AVMs are comon cause of GIB in LVAD
UBRS can be used to predict GIB in LVAD recipients
Transfusing to Hb > 7 and for significant bleeds holding a/c and lets say melena: EGD +/- Colo No Lesion?
Summary-2
Continued Bleed? Capsule Endoscopy? Angio? Tagged RBC Scan?
ry(Omega-3-FA, ?Digoxin), ry (Thalidomide, Octreotide, Danazol,Tamoxifen, Bevacizumab) prevention of GIB
Continued Bleed? Capsule Endoscopy? Angio? Tagged RBC Scan?
ry(Omega-3-FA, ?Digoxin), ry (Thalidomide, Octreotide, Danazol,Tamoxifen, Bevacizumab) prevention of GIB
I learned something in this Tweetorial that may change my clinical practice
Many thanks to @ThomasMDas @Cardionerds @karanpdesai @AmitGoyalMD Academy for their feedback and support!