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Journal ArticleDOI

Arteriovenous malformation and gastrointestinal bleeding in patients with the HeartMate II left ventricular assist device.

TL;DR: Arteriovenous malformations can cause GI bleeding in patients with continuous-flow LVADs and in all cases in this series, GI bleeding was successfully managed without the need for surgical intervention.
Abstract: Background In this study we investigated gastrointestinal (GI) bleeding and its relationship to arteriovenous malformations (AVMs) in patients with the continuous-flow HeartMate II (HMII) left ventricular assist device (LVAD). Methods The records of 172 patients who received HMII support between November 2003 and June 2010 were reviewed. Patients were considered to have GI bleeding if they had 1 or more of the following symptoms: guaiac-positive stool; hematemesis; melena; active bleeding at the time of endoscopy or colonoscopy; and blood within the stomach at endoscopy or colonoscopy. The symptom(s) had to be accompanied by a decrease of >1 g/dl in the patient's hemoglobin level. The location of the bleeding was identified as upper GI tract, lower GI tract or both according to esophagogastroduodenoscopy, colonoscopy, small-bowel enteroscopy or mesenteric angiography. Post-LVAD implantation anti-coagulation therapy consisted of warfarin, aspirin and dipyridamole. Results Thirty-two of the 172 patients (19%) had GI bleeding after 63 ± 62 (range 8 to 241) days of HMII support. Ten patients had GI bleeding from an AVM; these included 3 patients who had 2 bleeding episodes and 2 patients who had 5 episodes each. Sixteen patients had upper GI bleeding (10 hemorrhagic gastritis, 4 gastric AVM, 2 Mallory–Weiss syndrome), 15 had lower GI bleeding (6 diverticulosis, 6 jejunal AVM, 1 drive-line erosion of the colon, 1 sigmoid polyp, 1 ischemic colitis) and 1 had upper and lower GI bleeding (1 colocutaneous and gastrocutaneous fistula). All GI bleeding episodes were successfully managed medically. Conclusions Arteriovenous malformations can cause GI bleeding in patients with continuous-flow LVADs. In all cases in this series, GI bleeding was successfully managed without the need for surgical intervention.
Citations
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Journal ArticleDOI
TL;DR: Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine, and Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama, Teuteberg JJ:University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs.
Abstract: Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan Contributing writers Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children’s Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul’s Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany Independent reviewers Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina

1,152 citations

Journal ArticleDOI
TL;DR: A deeper understanding of how these devices perturb the delicate intrinsic balance of bleeding and thrombosis is critical to guide therapy and to overcome the current obstacles to achieving a long-term safety profile comparable to that of mechanical prosthetic valves.
Abstract: Because of the obligate intravascular location of contemporary continuous-flow ventricular assist devices (CF-VADs), it is not surprising that bleeding and thrombosis are among the most common and feared complications of this therapy, respectively. Although strides have been made in our understanding of the pathophysiology of continuous flow, intravascular CF-VADs have been widely used only in the last few years, and a great deal remains less well known (or unknown). Outcomes have improved significantly over the past decade, but a deeper understanding of how these devices perturb the delicate intrinsic balance of bleeding and thrombosis is critical to guide therapy and to overcome the current obstacles to achieving a long-term safety profile comparable to that of mechanical prosthetic valves. ### Hematologic Effect of CF-VADs The hematologic effects of CF-VADs are of significant interest and importance and have recently been reviewed in detail elsewhere.1,2 Hemocompatibility refers to the interaction of prosthetic material with blood and can be measured in terms of impact on hematologic, inflammatory, or immunologic parameters, which has been observed clinically as significant and prolonged activation of endothelial and coagulation systems after CF-VAD implantation, including intercellular adhesion molecule, E-selectin, and tissue factor, for example.3 Hemocompatibility has always been a goal in pump design, along with efforts to maximize blood flow without clinically significant hemolysis, areas of stasis, turbulent flow, or retrograde flow. It has been suggested that the major complications of thrombosis, bleeding, and infection could be related to the effects of blood interaction with the VAD surface,4,5 and further optimization of surface coatings presents an appealing strategy for additional exploration.6 A better understanding of the impact of blood–VAD surface interactions with the presently used CF-VAD devices, however, is essential to evaluating the impact of novel designs or materials. A few recent observations have provided some insight …

266 citations

Journal ArticleDOI
TL;DR: Advances in the understanding of the pathological mechanisms underlying bleeding/thrombosis risk, careful risk stratification, and potential use of novel anticoagulants will all play a role in the management of the LVAD patient.
Abstract: During the past several decades, left ventricular assist devices (LVADs) have become a valuable therapeutic option in the management of advanced systolic heart failure. Durable LVADs are being used to provide long-term mechanical circulatory support to a growing population of patients with end-stage systolic heart failure refractory to medical and electric therapies. This advanced stage of heart failure is associated with unacceptably high mortality when treated with medical therapy alone, and these patients are traditionally referred for cardiac transplantation.1,2 Unfortunately, the number of heart transplantations performed in the United States is limited by the availability of donor organs to ≈2200 per year, a small fraction of the total patients requiring advanced heart failure care.3 Moreover, 75% of patients with end-stage heart failure are >65 years and have severe comorbid conditions, making them ineligible for transplantation at many centers.4 As a result of innovative trials, LVADs have become a therapeutic option in patients with end-stage heart failure as bridge-to-transplantation or destination therapy in patients deemed ineligible for cardiac transplantation.5,6 Contemporary LVADs are continuous-flow pumps that allow for smaller pump size and improved mechanical reliability and durability.7 In a landmark study8 comparing the HeartMate XVE, an older first-generation pulsatile pump (Thoratec Corp; Pleasanton, CA), with the newer HeartMate II LVAD (Thoratec Corp), the continuous-flow pump outperformed the pulsatile device in overall survival, pump failure events, and infectious complications. Device technology continues to improve, and third-generation continuous-flow LVADs under development use magnetic or hydrodynamic bearings for frictionless rotation of the rotor that may further enhance durability.9 One potential limitation of continuous-flow pump technology is the relatively high nonphysiological shear stress imparted on blood components as they move through the device. This stress, coupled with the reduced pulse pressure associated with axial-flow LVADs, …

239 citations

Journal ArticleDOI
TL;DR: It is anticipated that the patient selection process outlined in the present review will continue to shift toward less advanced cases of heart failure, and the continuing simplification of design along with continued reduction in size of the devices, plus eventual elimination of the external drive line will make the use of VADs a superior option to heart transplant and even to medical management in many patients.

224 citations

Journal ArticleDOI
TL;DR: The evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
Abstract: Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

220 citations

References
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Journal ArticleDOI
TL;DR: Von Willebrand factor abnormalities are directly related to the severity of aortic stenosis and are improved by valve replacement in the absence of mismatch between patient and prosthesis.
Abstract: Background Aortic-valve stenosis can be complicated by bleeding that is associated with acquired type 2A von Willebrand syndrome. However, the prevalence and cause of the hemostatic abnormality in aortic stenosis are unknown. Methods We enrolled 50 consecutive patients with aortic stenosis, who completed a standardized screening questionnaire to detect a history of bleeding. Forty-two patients with severe aortic stenosis underwent valve replacement. Platelet function under conditions of high shear stress, von Willebrand factor collagen-binding activity and antigen levels, and the multimeric structure of von Willebrand factor were assessed at base line and one day, seven days, and six months postoperatively. Results Skin or mucosal bleeding occurred in 21 percent of the patients with severe aortic stenosis. Platelet-function abnormalities under conditions of high shear stress, decreased von Willebrand factor collagen-binding activity and the loss of the largest multimers, or a combination of these was pres...

739 citations


"Arteriovenous malformation and gast..." refers background in this paper

  • ...After aortic valve replacement in patients with aortic stenosis and bleeding AVMs, HMW vWF multimers increase and GI bleeding resolves.(7,8) In continuous-flow LVADs, the impeller mechanism may also cause vWF deformation, proteolysis and a deficiency of HMW vWF multimers....

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Journal Article
TL;DR: After hemorrhage from colonic diverticulosis, the leading cause, rates of ALGIH recurrence and unrelated death are similar during the next 4 years, which is related to age and male gender.

685 citations


"Arteriovenous malformation and gast..." refers background in this paper

  • ...Forty to 60% of patients with an AVM have more than one; each AVM may cause occult or overt GI bleeding.(10) Multiple AVMs may occur anywhere in the GI tract, either in disparate regions or in a single region....

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Journal ArticleDOI
TL;DR: Patients with nonpulsatile left ventricular assist devices appear to have a higher rate of gastrointestinal bleeding events than do pulsatile left Ventricular assist device recipients.

459 citations


"Arteriovenous malformation and gast..." refers background in this paper

  • ...Gastrointestinal AVMs are a risk factor for GI bleeding.(9) The prevalence of GI AVMs in the general population is not clear....

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Journal ArticleDOI
TL;DR: These investigations suggested that vascular ectasias developing as a degenerative process of aging, are present with or without bleeding in a significant portion of the population over 60 years of age, are multiple more often than single, and may represent the commonest cause of major lower intestinal bleeding in the elderly.

447 citations

Journal Article

345 citations


"Arteriovenous malformation and gast..." refers background in this paper

  • ...The association between colonic AVMs and aortic valve stenosis was first described by Heyde.5 Boley et al6 reported a 15% prevalence of aortic stenosis in patients with vascular ectasias of the colon....

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  • ...The association between colonic AVMs and aortic valve stenosis was first described by Heyde.(5) Boley et al(6) reported a 15% prevalence of aortic stenosis in patients with vascular ectasias of the colon....

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