Gastrointestinal Bleeding Ceases after Heart Transplantation in Patients Bridged on Continuous-Flow LVAD Support

Purpose Continuous flow left ventricular assist device (CF-LVAD) support has been associated with gastrointestinal bleeding (GIB), primarily from arteriovenous malformations or ulcers, and exacerbated by the requirement for anticoagulation. In this report, we explore whether GIB persisted after heart transplant in patients who experienced GIB events while on CF-LVAD support. Methods We performed a retrospective review of 701 patients who underwent implantation of CF-LVADs from August 2002 through August 2017 at our center, and identified patients who underwent CF-LVAD implantation as a Bridge-to-Transplant, experienced at least one GIB event during CF-LVAD support, and were successfully bridged to heart transplantation. We evaluated the incidence of GIB events in these patients after heart transplantation. Results A total of 46 heart transplant recipients fit the inclusion criteria. There were a total of 63 total GIB events while on CF-LVAD support. Locations of GIB events included esophagus (N=3), stomach (N=21), duodenum (N=7), jejunum (N=3), small intestine not-otherwise-specified (N=12), colon (N=14), and rectum (N=3). Etiologies included gastritis (N=10), ulcer (N=11), arteriovenous malformation (N=13), angiodysplasia (N=3), polyp (N=2), diverticulosis (N=8), and Mallory Wiess tear (N=2). Mean LVAD support time was 1.4±1.5 years (65.4 cumulative patient-years). Mean follow-up time after transplantation was 4.0±3.5 years (183.3 cumulative patient-years after transplantation). There was only 1 GIB event after heart transplantation (events per patient-year: 0.005). The etiology was non-specific acute colitis in a patient who had prior GIB from a gastric ulcer while on LVAD therapy. Time from transplant to GIB event was 3.9 years. The patient was taking aspirin 81mg daily at the time of GIB. Conclusion GIB during CF-LVAD therapy did not persist after heart transplantation. This may be due to restoration of pulsatile flow. Introduction of a greater degree of pulsatility into LVAD flow technology may improve the incidence of GIB while on CF-LVAD support.