Marsano Joseph, Desai Jay, Chang Shannon, Chau Michelle, Pochapin Mark, Gurvits Grigoriy E
Department of Medicine, New York University School of Medicine, New York, NY, USA.
Dig Dis Sci. 2015 Jun;60(6):1859-67. doi: 10.1007/s10620-015-3538-7. Epub 2015 Jan 24.
Medical management of patients with continuous-flow left ventricular assist devices (LVADs) remains challenging for the gastroenterologist given their high risk of gastrointestinal bleeding (GIB) and need for continuous anticoagulation.
Our aim was to better characterize LVAD patients who presented with a GIB at our facility and delineate the prevalence, presentation, time to diagnosis, management, and therapeutic endoscopic interventions, including small bowel tools that may offer additional benefit.
We retrospectively reviewed adult patients (>18 years) who underwent LVAD implantation at our tertiary care facility between October 2011 and October 2013. Electronic medical records were reviewed for presenting symptoms, average days to initial and repeat GIB, hospital course, and techniques that led to diagnosis and hemostasis.
Eighteen patients underwent LVAD implantation, of which 61 % presented with a GIB for a total of 20 presentations (1.8 per patient). Mean time to initial GIB was 154 days. Patients required an average of 1.8 endoscopic procedures per admission. Esophagogastroduodenoscopy (EGD) and push enteroscopy (PE) were more likely to lead to a diagnosis, and EGD was the most commonly used diagnostic tool at initial presentation. Sixty percent of patients who initially received EGD presented with a recurrent GIB and required PE, which was diagnostic and therapeutic for small bowel angiodysplasias in 80 % of cases.
We found a higher GIB rate compared with prior studies. Bleeding events were associated with multiple procedures and interventions. We recommend an algorithmic approach to LVAD patients who bleed. Our experience suggests that PE is warranted at initial presentation in order to achieve hemostasis, prevent recurrent GIB, and decrease subsequent readmission rates.
对于胃肠病学家而言，连续血流左心室辅助装置（LVAD）患者的医疗管理仍然具有挑战性，因为这些患者有较高的胃肠道出血（GIB）风险且需要持续抗凝。
我们的目的是更好地描述在我们机构出现GIB的LVAD患者特征，并确定其患病率、表现、诊断时间、管理及治疗性内镜干预措施，包括可能带来额外益处的小肠检查手段。
我们回顾性分析了2011年10月至2013年10月在我们三级医疗中心接受LVAD植入的成年患者（>18岁）。查阅电子病历以了解其出现的症状、首次和再次发生GIB的平均天数、住院过程以及导致诊断和止血的技术。
18例患者接受了LVAD植入，其中61%出现了GIB，共20次（每位患者1.8次）。首次发生GIB的平均时间为154天。每位患者每次入院平均需要1.8次内镜检查。食管胃十二指肠镜检查（EGD）和推进式小肠镜检查（PE）更有可能实现诊断，且EGD是初次就诊时最常用的诊断工具。最初接受EGD检查的患者中有60%出现复发性GIB且需要PE检查，其中80%的病例中PE对小肠血管发育异常具有诊断和治疗作用。
我们发现GIB发生率高于先前研究。出血事件与多种检查和干预措施相关。我们建议对出血的LVAD患者采用程序化方法。我们的经验表明，初次就诊时进行PE检查有助于实现止血、预防复发性GIB并降低随后的再入院率。
