Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 28, 2020; 26(20): 2550-2558
Published online May 28, 2020. doi: 10.3748/wjg.v26.i20.2550
Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review
Srikanth Vedachalam, Gokulakrishnan Balasubramanian, Garrie J Haas, Somashekar G Krishna
Srikanth Vedachalam, Department of Internal Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
Gokulakrishnan Balasubramanian, Somashekar G Krishna, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
Garrie J Haas, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
Author contributions: Vedachalam S and Krishna SG designed the structure of this manuscript; Vedachalam S, Krishna SG, and Balasubramanian G drafted the manuscript and contributed critical revisions to this manuscript; Haas GJ contributed critical revisions to this manuscript.
Conflict-of-interest statement: None of the authors have any conflicts of interest or financial ties to disclose related to the current study.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Somashekar G Krishna, MD, Associate Professor, Director of Clinical Research, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Suite 262, Columbus, OH 43210, United States.
Received: February 25, 2020
Peer-review started: February 25, 2020
First decision: April 22, 2020
Revised: May 2, 2020
Accepted: May 14, 2020
Article in press: May 14, 2020
Published online: May 28, 2020

Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.

Keywords: Left ventricular assist device, Push enteroscopy, Double balloon enteroscopy, Video capsule endoscopy, Octreotide, Bevacizumab, Gastrointestinal bleeding

Core tip: Left ventricular assist devices are becoming increasingly common as life-prolonging therapy in advanced heart failure. However, left ventricular assist devices have shown high rates of gastrointestinal bleeding with 18%-40% of patients having episodes of bleed. Arteriovenous malformations are primarily responsible, which can be both challenging to control and cause many patients to discontinue essential anti-platelet and anti-coagulation therapies. Small bowel lesions are common in this population, frequently requiring small bowel endoscopic evaluation. For refractory cases, medical management is required including octreotide, thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based therapies, desmopressin, doxycycline or bevacizumab to prevent further gastrointestinal bleeding.