Thread by @DeveshRaiMD, #CardioTwitter #CardioNerds #GITwitter How do you approach GI Bleed in patients with [...]

#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

#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

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

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

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?

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

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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 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

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

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

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

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)

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)

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 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

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

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/32wRNdo

However, be cautious with the side-effect profile of these drugs

Novel Use of Tamoxifen to Reduce Recurrent Gastrointestinal Bleeding in Patients with Left Ventri...

Gastrointestinal bleeding (GIB) is a frequent complication in patients with continuous-flow left ventricular assist devices (LVAD). We retrospectively evaluated eight patients implanted with a...

https://bit.ly/3dzZsOj

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