Diagnostic Yield of Endoscopy Procedures in the Management of Left Ventricular Assist Device Recipients Presenting with Gastrointestinal Bleeding

Purpose Left ventricular assist device (LVAD) patients are predisposed to gastrointestinal bleeding (GIB) due to a combination of anticoagulation/antiplatelet medications and continuous flow physiology of LVADs, resulting in arteriovenous malformations. The workup for GIB often includes multiple endoscopic procedures resulting in prolonged hospital length of stay (LOS). Methods A single center retrospective review was performed on adult patients between 2011 and 2017 for patients receiving LVAD and having a GIB event within 1 year after implantation. The types of procedure, clinical findings, and endoscopy results were recorded. Results We included 54 subjects, accounting for 164 endoscopies from 111 GIB events. The most utilized exam was upper GI endoscopy (UGE; 50% of all procedures). Diagnostic yield leading to treatment was highest for double balloon enteroscopy (DBE) (65%; Fig 1A) and lowest for UGE (40%) with similar frequencies for lesion identification (Fib 1B). There were 50 patients presenting with their first GIB concerning for an upper GI source, of which 42 received UGE. A lesion was identified in 25 (50%) of these cases, and treatment administered in 13 (25%). For subsequent endoscopy procedures, diagnostic yield for push enteroscopy (PE) was 76% and 71% for DBE. There were 28 (52%) patients that had re-bleeding within 1 year; the median number of bleeding events per person was 2 [1, 2.75] and the median number of endoscopies needed per person was 2 [2, 4]. There were 117 (71%) endoscopies that identified culprit lesions and 79 (48%) resulted in 1 or more treatment. Median LOS for patients who received DBE was 8 days, compared to 5 days for those with no DBE. Conclusion Initial endoscopic evaluation with DBE or PE rather than UGE would serve to increase the yield of finding a culprit lesion and decrease LOS in patients with LVAD admitted for GIB. Additional studies to identify patients at high risk of recurrent GIB are needed.