Shah Rushikesh, Qayed Emad
From the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia.
South Med J. 2018 Nov;111(11):666-673. doi: 10.14423/SMJ.0000000000000883.
Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients.
We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders.
A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, < 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, < 0.0001), and longer (12 vs 10.9 days, < 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, < 0.0001) and GI bleeding during index admission (aHR 2.68, < 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, = 0.14).
After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.
胃肠道（GI）出血是左心室辅助装置（LVAD）患者的主要合并症。本研究旨在利用全国代表性数据库估计LVAD患者因GI出血再次入院的发生率。此外，我们评估了这些患者GI出血再次入院的病因、费用、内镜检查的使用情况、死亡率及预测因素。
我们分析了2010年至2014年国家再入院数据库（NRD）中的数据。我们将接受LVAD植入术的充血性心力衰竭（CHF）住院成年患者（病例组）与未接受LVAD或心脏移植的CHF患者（对照组）进行比较。每个病例随机选取3名年龄和性别匹配的对照。采用多变量Cox回归模型比较两组60天全因再入院和GI出血再入院的风险，并对显著的混杂因素进行控制。
本研究共纳入3293例接受LVAD植入术的CHF住院患者（病例组）和9879例未接受LVAD植入术的患者（对照组）。60天时，LVAD患者因GI出血再次入院的发生率显著更高（8.7%对2.3%，调整后风险比[aHR]4.45，95%置信区间3.7⒈5.33，P<0.0001）。全因再入院率也更高（43.3%对35.7%，aHR⒈23，95%置信区间⒈12⒈34，P<0.0001）。LVAD患者出血的最常见病因是胃十二指肠和小肠动静脉畸形（28.6%）。与对照组相比，LVAD患者在出血再次入院期间更有可能接受内镜检查（72.1%对33.5%，P<0.0001）和接受浓缩红细胞输注（62%对36.6%，P<0.0001）。与对照组相比，LVAD患者因GI出血再次入院的费用更高（40936美元对35313美元，P<0.0001），住院时间更长（12天对10.9天，P<0.0001）。60天GI出血再入院的独立危险因素是年龄增加（aHR⒈04，P<0.0001）和首次入院期间发生GI出血（aHR⒈68，P<0.0001）。在首次入院期间未发生出血的患者中，年龄增加和慢性贫血与60天GI出血再入院有关。与CHF对照组相比，LVAD患者出血再次入院期间的死亡率同样较低（0.2%对0.3%，P⒈4）。
LVAD植入术后，60天内因GI出血再次入院的风险增加了五倍。胃十二指肠和小肠动静脉畸形是最常见的病因。这些发现表明，对于疑似上胃十二指肠出血的患者，小肠镜检查应被视为首选的初始检查。LVAD患者出血再次入院会增加发病率和护理费用，但不会增加死亡率。老年患者和LVAD植入期间有出血史的患者出血再次入院的风险更高，可能受益于密切监测和谨慎抗凝以预防再次出血。
