RV dysfunction tied to GI bleeding risk after continuous-flow LVAD placement

Last Updated: 2015-11-25

By Shannon Aymes

NEW YORK (Reuters Health) - A history of severe right ventricular dysfunction may be associated with an increased risk for gastrointestinal bleeding after placement of a continuous-flow left ventricular assist device (LVAD), according to a new study.

"Bleeding is the most common complication in LVAD patients and it remains the leading cause of re-hospitalization after device implant," said senior author Dr. Joel Schilling from Washington University School of Medicine, St. Louis, Missouri.

"To date, the ability to predict the risk of GIB (gastrointestinal bleeding) prior to device implant has been limited," he told Reuters Health by email. "Given that RV (right ventricular) dysfunction is associated with several characteristics that could increase bleeding risk such as decreased LV pulsitility, increased venous pressures, and coagulopathy, we investigated the relationship between pre-operative RV function and the risk of post-LVAD GI bleeding."

The findings were published online October 31 in JACC: Heart Failure.

Dr. Schilling and colleagues analyzed data from 212 patients who received CF-LVADs between 2009 and 2013. RV function was assessed with pre-operative transthoracic echocardiograms and interpreted independently; 37 had severe RV dysfunction and 175 patients had normal to moderate RV dysfunction (control).

The primary outcomes was freedom of GIB, defined as clinically evident or occult GIB leading to hospitalization and endoscopic evaluation. Most of the study participants were males (79%) and there were no significant differences between the groups for demographics, aspirin dose, international normalized ratio, LVAD device type, or comorbidities.

During a median follow-up of 0.93 year, 81 participants developed a GI bleeding event (62% of the severe-RV group vs. 33% of the control group, p=0.001). The six-month estimated event-free rate was 72% in the control group compared to 54% among patients with severe RV dysfunction (p=0.04).

Severe RV dysfunction was still associated with an increased risk of GI bleeding after adjusting for ischemic cardiomyopathy and age (HR, 1.8; p=0.022).

"Based on the findings of this study, we are currently incorporating RV function parameters with additional clinical predictors of bleeding to develop a clinically useful tool for assessing bleeding risk before LVAD implant," Dr. Schilling said. "Such information could help in counseling patients about the likelihood of GI bleeding complications after LVAD and facilitate pre-emptive alterations in anticoagulation goals to reduce bleeding events."

Dr. David L. Joyce, a cardiothoracic surgeon at Mayo Clinic in Rochester, Minnesota, who was not involved in the study, said RV dysfunction is the "'Achilles heel' of LVAD surgery."

"While the LVAD represents a cure for most patients with advanced heart failure, the success of the operation depends on having enough right ventricular reserve to achieve optimal circulation," he told Reuters Health by email.

"As many as 20% of patients manifest some degree of RV dysfunction after LVAD surgery, and this typically results in longer ICU stay, hospital stay, and complication rates," Dr. Joyce said. "GI bleeding represents another challenging complication of LVAD surgery, accounting for the majority of readmissions. Until now, these two complications have not been linked in any meaningful way."

Dr. Joyce added, "This discovery should refocus our interest in understanding and optimizing RV function given that it appears to be associated with outcomes as they relate to bleeding complications. At this point, we still don't understand the mechanisms to explain this very interesting correlation between RV dysfunction and GI bleeding. In general, RV dysfunction identifies a sicker cohort of patients that may be predisposed to a variety of complications beyond GI bleeding."

The authors report no disclosures.

SOURCE: http://bit.ly/1lJJXFS

JACC Heart Fail 2015.