A reappraisal of the pharmacologic management of gastrointestinal bleeding in patients with continuous flow left ventric
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A reappraisal of the pharmacologic management of gastrointestinal bleeding in patients with continuous flow left ventricular assist devices Audrey J. Littlefield 1 & Gregory Jones 1 & Alana M. Ciolek 2 & Melana Yuzefpolskaya 3 & Douglas L. Jennings 2,4 Accepted: 21 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Advancements in the design and functionality of continuous flow left ventricular assist devices (CF-LVADs), as well as a limited number of donor hearts, have resulted in an increased utilization of this therapy among advanced heart failure (HF) patients. Despite these advancements, gastrointestinal bleeding (GIB) remains a common complication after CF-LVAD implantation. The mechanism of GIB in these patients is complex and includes a combination of angiodysplasia, platelet dysfunction, acquired von Willebrand disease, and a variety of patient-specific factors including advanced age and history of GIB. Several pharmacotherapy options have been reported in the literature, though studies supporting the use of these agents are often small, retrospective reports. Within this review, we discuss the various pharmacologic agents, their proposed mechanisms of action, and the available literature pertaining to their effectiveness and tolerability. Additionally, we propose an evidence-based treatment algorithm, encompassing the updated literature, cost of therapy, medication side effects, and ease of administration. Keywords Gastrointestinal bleed . Left ventricular assist device . Heart failure
The prevalence of heart failure (HF) continues to increase at an alarming rate, approaching 6.5 million cases in the USA alone, with approximately 10% of patients progressing to advanced stages [1]. Although heart transplant (HT) remains the gold standard treatment for end-stage HF, limited donor organ availability has prohibited the annual rate in the USA from exceeding 3400 transplants per year [2]. Conversely, the annual rate of continuous flow left ventricular assist device (CFLVAD) implantation—used not only as a bridge to transplantation (BTT) but also as destination therapy (DT)—has steadily risen to over 2500 implantations per year in 2017, rescuing an increasing number of failing hearts [3]. With increased utilization of CF-LVADs, documentation and characterization
of associated complications have also improved. Behind infection, gastrointestinal bleeding (GIB) has been reported as the second most common complication, occurring in 24–31% of cases [4–6], and the most common reason for readmission [7]. CF-LVAD recipients also experience greater severity of GIB events than the general population, potentially jeopardizing the transplant candidacy for those patients whose indication strategy is BTT [8]. As such, understanding the pathophysiological mechanisms and outlining the algorithms for management of GIB in patients with CF-LVADs are of utmost importance.
Pathophysiology * Douglas L. Jennings [email protected] 1
NewYork-Presbyterian Hospital, Weill Cornell Me
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