#CardioTwitter #CardioNerds #GITwitter How do you approach GI Bleed in patients with LVAD, we& #39;ll follow a patient from presentation to discharge

72 Y/F s/p LVAD 1 year ago presented with https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">in https://abs.twimg.com/emoji/v2/... draggable="false" alt="💩" title="Dreckshaufen" aria-label="Emoji: Dreckshaufen">

Learning objectiveshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="😎" title="Lächelndes Gesicht mit Sonnenbrille" aria-label="Emoji: Lächelndes Gesicht mit Sonnenbrille">https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">

https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">Identification GIB in a patient with LVAD

https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">Predictive factors for LVAD and GIB

https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">Diagnosis and management approach of GIB & LVADhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🆎" title="Negatives quadratisches AB" aria-label="Emoji: Negatives quadratisches AB">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🅰️" title="Invertierter quadratischer lateinischer Buchstabe A" aria-label="Emoji: Invertierter quadratischer lateinischer Buchstabe A">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🅱️" title="Invertierter quadratischer lateinischer Buchstabe B" aria-label="Emoji: Invertierter quadratischer lateinischer Buchstabe B">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🅾️" title="Invertierter quadratischer lateinischer Großbuchstabe o" aria-label="Emoji: Invertierter quadratischer lateinischer Großbuchstabe o">

https://abs.twimg.com/emoji/v2/... draggable="false" alt="☑️" title="Kästchen mit Häkchen" aria-label="Emoji: Kästchen mit Häkchen">Primary and Secondary prevention of recurrent GIB

I feel comfortable in diagnosing, treating, and preventing #GIB in patients with #LVAD.

Patient-reported dizziness and blood in https://abs.twimg.com/emoji/v2/... draggable="false" alt="💩" title="Dreckshaufen" aria-label="Emoji: Dreckshaufen"> for the last 1 month

Lab work revealed a drop in Hb from 8 to 6 https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">(3 months ago), INR has been therapeutic since LVAD implant.https://abs.twimg.com/emoji/v2/... draggable="false" alt="🫀" title="Anatomical heart" aria-label="Emoji: Anatomical heart">

So what do we do next?

First off, what defines GIB in LVAD patientshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="❓" title="Rotes Fragezeichen-Symbol" aria-label="Emoji: Rotes Fragezeichen-Symbol">

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 https://abs.twimg.com/emoji/v2/... draggable="false" alt="💩" title="Dreckshaufen" aria-label="Emoji: Dreckshaufen">

#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 ">https://bit.ly/32sPo3e&q...

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:

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">Low : 0-1

https://abs.twimg.com/emoji/v2/... draggable="false" alt="↔️" title="Links-rechts-Pfeil" aria-label="Emoji: Links-rechts-Pfeil">Intermediate: 2-4

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">High: 5-9

Back to https://abs.twimg.com/emoji/v2/... draggable="false" alt="👨‍🦱" title="Man, curly haired" aria-label="Emoji: Man, curly haired">, after acute stabilization:

Transfusing https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏥" title="Krankenhaus" aria-label="Emoji: Krankenhaus"> to Hb > 7, stop a/c

EGD +/- Colo https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> No Lesion

The following can be considered:

https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> Capsule Endoscopy? https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">Angio? https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">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& #39;s endoscopic algorithm for GIB in CF-LVAD patients? Leave in the comments below!

Back to https://abs.twimg.com/emoji/v2/... draggable="false" alt="👨‍🦱" title="Man, curly haired" aria-label="Emoji: Man, curly haired">

(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 
https://bit.ly/3svQmq0&q... href="https://twtext.com//hashtag/GIB"> #GIB #CardioTwitter

#GIB #CardioTwitter" title="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&q... href="https://twtext.com//hashtag/GIB"> #GIB #CardioTwitter" class="img-responsive" style="max-width:100%;"/>

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 strategieshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🪧" title="Placard" aria-label="Emoji: Placard">.

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.

The proposed mechanism for these medications are as follows:

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/3dzZsOj&q...

https://bit.ly/32wRNdo ">https://bit.ly/32wRNdo&q...

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 VIOLAhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🎊" title="Konfettiball" aria-label="Emoji: Konfettiball">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🎆" title="Feuerwerk" aria-label="Emoji: Feuerwerk">!! no new episodes of GIB over 6 months!

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔥" title="Feuer" aria-label="Emoji: Feuer">Summary -1 https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔥" title="Feuer" aria-label="Emoji: Feuer">

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✅" title="Fettes weißes Häkchen" aria-label="Emoji: Fettes weißes Häkchen">AVMs are comon cause of GIB in LVAD

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✅" title="Fettes weißes Häkchen" aria-label="Emoji: Fettes weißes Häkchen">UBRS can be used to predict GIB in LVAD recipients

Transfusinghttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏥" title="Krankenhaus" aria-label="Emoji: Krankenhaus"> to Hb > 7 and for significant bleeds holding a/c and lets say melena: EGD +/- Colo https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> No Lesion?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔥" title="Feuer" aria-label="Emoji: Feuer">Summary-2https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔥" title="Feuer" aria-label="Emoji: Feuer">

https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> Continued Bleed? https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> Capsule Endoscopy? https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">Angio? https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">Tagged RBC Scan?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✅" title="Fettes weißes Häkchen" aria-label="Emoji: Fettes weißes Häkchen">https://abs.twimg.com/emoji/v2/... draggable="false" alt="1⃣" title="Tastenkappe Ziffer 1" aria-label="Emoji: Tastenkappe Ziffer 1">ry(Omega-3-FA, ?Digoxin), https://abs.twimg.com/emoji/v2/... draggable="false" alt="2⃣" title="Tastenkappe Ziffer 2" aria-label="Emoji: Tastenkappe Ziffer 2">ry (Thalidomide, Octreotide, Danazol,Tamoxifen, Bevacizumab) prevention of GIB

I feel comfortable in diagnosing, treating, and preventing #GIB in patients with #LVAD.

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!