Thohan Vinay, Shi Yang, Rappelt Matthew, Yousefzai Rayan, Sulemanjee Nasir Z, Hastings Thomas E, Cheema Omar M, Downey Frank, Crouch John D
Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin.
Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin.
J Card Surg. 2019 Jun;34(6):453-462. doi: 10.1111/jocs.14062. Epub 2019 May 6.
This study explores novel preimplantation risk factors associated with gastrointestinal bleeding (GIB) after continuous-flow left ventricular assist device (CF-LVAD) implantation. CF-LVAD therapy implantation for patients with advanced heart failure is associated with a 20% to 40% incidence of GIB.
This study includes patients receiving CF-LVAD at a quaternary medical center from 2006 to 2014 (n = 254). The primary endpoint was GIB within 12 months after implantation; the secondary outcome was 3-year all-cause mortality. The Student t test or the χ test compared continuous or categorical variables. Competing risks analysis calculated the cumulative incidence of GIB postimplantation. Cox proportional hazards model was used for univariate/multivariate models predicting GIB.
Sixty-four patients had GIB, with incidence rates at 1, 3, and 12 months of 11.8%, 19.3%, and 25.2%, respectively. Endoscopy revealed no identified source of bleeding in 41%; 33% of lesions were localized in the upper gastrointestinal tract, with the bulk (39%) categorized as vascular. Patients with prior gastrointestinal abnormalities (n = 98) had a greater risk of GIB post-CF-LVAD (HR 1.85 [1.11-3.09]; P = 0.02) than those with normal gastrointestinal evaluation results (n = 45) and those without preimplantation gastrointestinal evaluation (n = 111). Baseline blood urea nitrogen, chronic obstructive pulmonary disease, and prior percutaneous coronary intervention were statistically associated with post-CF-LVAD GIB. The presence of GIB within 12 months of CF-LVAD implantation was associated with an increased risk of 3-year all-cause mortality (HR 2.57 [1.57-4.15]; P < 0.01).
First-year GIB is associated with increased mortality post-CF-LVAD. We advocate a closer examination of several GIB risk factors when evaluating CF-LVAD candidates.
本研究探讨了连续流左心室辅助装置（CF-LVAD）植入术后与胃肠道出血（GIB）相关的新的植入前风险因素。晚期心力衰竭患者接受CF-LVAD治疗植入术后GIB发生率为20%至40%。
本研究纳入了2006年至2014年在一家四级医疗中心接受CF-LVAD治疗的患者（n = 254）。主要终点为植入后12个月内发生的GIB；次要结局为3年全因死亡率。采用Student t检验或χ检验比较连续变量或分类变量。竞争风险分析计算植入后GIB的累积发生率。Cox比例风险模型用于预测GIB的单变量/多变量模型。
64例患者发生GIB，1个月、3个月和12个月时的发生率分别为11.8%、19.3%和25.2%。内镜检查发现41%的患者未明确出血源；33%的病变位于上消化道，其中大部分（39%）为血管性病变。既往有胃肠道异常的患者（n = 98）在CF-LVAD植入后发生GIB的风险（HR 1.85 [1.11 - 3.09]；P = 0.02）高于胃肠道评估结果正常的患者（n = 45）和植入前未进行胃肠道评估的患者（n = 111）。基线血尿素氮、慢性阻塞性肺疾病和既往经皮冠状动脉介入治疗与CF-LVAD植入后GIB在统计学上相关。CF-LVAD植入后12个月内发生GIB与3年全因死亡率增加相关（HR 2.57 [1.57 - 4.15]；P < 0.01）。
第一年发生的GIB与CF-LVAD植入术后死亡率增加相关。我们主张在评估CF-LVAD候选者时更密切地检查几种GIB风险因素。
