Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA.
Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA.
J Heart Lung Transplant. 2018 Jun;37(6):723-732. doi: 10.1016/j.healun.2017.12.017. Epub 2017 Dec 20.
Gastrointestinal bleeding (GIB) is a frequent cause of re-admission in patients with continuous-flow left ventricular assist devices (CF-LVADs) and is associated with multiple endoscopic procedures and high resource utilization. Our aim was to determine the diagnostic and therapeutic yield of endoscopy and to develop a more cost-effective approach for the management of GIB in CF-LVAD recipients.
We retrospectively reviewed 428 patients implanted with a CF-LVAD between 2009 and 2016 at the Columbia University Medical Center and identified those hospitalized for GIB. Patients were categorized into upper GIB (UGIB), lower GIB (LGIB) and occult GIB (OGIB), based on clinical presentation.
Eighty-seven CF-LVAD patients underwent a total of 164 GIBs, resulting in 239 endoscopies. Index presentation was consistent with UGIB in 30 (34.5%), LGIB in 19 (21.8%) and OGIB in 38 (43.7%) patients. On the first GIB, 147 endoscopies localized a bleeding source in 49 (30%), resulting in 24 (16.3%) endoscopic interventions. Of 45 lesions identified, arteriovenous malformations (AVMs) were the most common (22, 48.9%). A gastric or small bowel source (HR 2.8, p = 0.003) and an endoscopic intervention (HR 1.9, p = 0.04) predicted recurrent GIB. The proposed algorithm may reduce the number of endoscopic procedures by 45% and costs by 35%.
Occult GIB is the most common presentation in CF-LVAD patients and carries the lowest diagnostic and therapeutic yield of endoscopy. Performing an intervention was among the strongest predictors of recurrent GIB. Our proposed algorithm may decrease the number of low-yield procedures and improve resource utilization.
胃肠道出血（GIB）是连续流动左心室辅助装置（CF-LVAD）患者再入院的常见原因，与多次内镜检查和高资源利用相关。我们的目的是确定内镜检查的诊断和治疗效果，并为 CF-LVAD 受者的 GIB 管理开发一种更具成本效益的方法。
我们回顾性分析了 2009 年至 2016 年间在哥伦比亚大学医学中心植入 CF-LVAD 的 428 例患者，并确定了因 GIB 住院的患者。根据临床表现，将患者分为上胃肠道出血（UGIB）、下胃肠道出血（LGIB）和隐匿性胃肠道出血（OGIB）。
87 例 CF-LVAD 患者共发生 164 次 GIB，行 239 次内镜检查。指数表现与 30 例（34.5%）、19 例（21.8%）和 38 例（43.7%）UGIB、LGIB 和 OGIB 患者一致。在首次 GIB 中，147 次内镜检查定位出血源 49 次（30%），行 24 次（16.3%）内镜治疗。45 个病变中，动静脉畸形（AVM）最常见（22 个，48.9%）。胃或小肠来源（HR 2.8，p=0.003）和内镜干预（HR 1.9，p=0.04）预测 GIB 再发。所提出的算法可使内镜检查次数减少 45%，成本减少 35%。
OGIB 是 CF-LVAD 患者最常见的表现，内镜检查的诊断和治疗效果最低。进行干预是 GIB 再发的最强预测因素之一。我们提出的算法可减少低收益操作的数量，提高资源利用率。
