Thread by @DeveshRaiMD

#CardioTwitter #CardioNerds #GITwitter How do you approach GI Bleed in patients with LVAD, we'll follow a patient from presentation to discharge

72 Y/F s/p LVAD 1 year ago presented with 🩸🩸in 💩

Learning objectives😎☑️☑️

☑️Identification GIB in a patient with LVAD

☑️Predictive factors for LVAD and GIB

☑️Diagnosis and management approach of GIB & LVAD🩸🩸🆎🅰️🅱️🅾️

☑️Primary and Secondary prevention of recurrent GIB

I feel comfortable in diagnosing, treating, and preventing #GIB in patients with #LVAD.

Patient-reported dizziness and blood in 💩 for the last 1 month

Lab work revealed a drop in Hb from 8 to 6 🩸(3 months ago), INR has been therapeutic since LVAD implant.🫀

So what do we do next?

First off, what defines GIB in LVAD patients❓

Any clinically suspected or documented bleeding from the GI tract, which can be indicated by new drop-in hgb and/or the appearance of melena, hematochezia, hematemesis, or guaiac-positive 💩

#GITwitter #CardioTwitter

The incidence of GIB varies, some reports indicate 15-40% in CF-LVAD patients

The most common etiology is AVM from 21% to 61%.

bit.ly/32sPo3e

The etiology and pathophysiology of #GIB in LVAD patients could be multifactorial as follows:

One study looked at a predictive model for LVAD and GIB: the Utah Bleeding Risk Score(UBRS) based on preimplant factors based on 351 LVAD recipients

Patients were stratified based on UBRS:

⬇️Low : 0-1

↔️Intermediate: 2-4

⬆️High: 5-9

Back to 👨‍🦱, after acute stabilization:

Transfusing 🩸🏥 to Hb > 7, stop a/c

EGD +/- Colo ➡ No Lesion

The following can be considered:

➡ Capsule Endoscopy? ➡Angio? ➡Tagged RBC Scan, intra-op enteroscopy?

See the Algorithms below for Active/Overt Bleeds

But what if the source is still hidden?

Algorithm for Obscure Occult Bleeding.

What is your institution's endoscopic algorithm for GIB in CF-LVAD patients? Leave in the comments below!

Back to 👨‍🦱

(Important considerations – a/c reversal, VAD speed adjustments if needed)

In terms of preventive strategies: ACEi/ARB, Digoxin, Omega-3-Fatty acids have all been retrospectively studied.

Our group performed network meta-analysis comparing these 3 meds, found Omega-3-FA is beneficial in primary prevention.
bit.ly/3svQmq0
#GIB #CardioTwitter

Our patient had an extensive w/up for Obscure overt bleeding with no identifiable etiology. After 5 days, the patient Hb continued to drop but remained stable and we focused on preventive strategies🪧.

The following is one a/c strategy in CF-LVAD and recurrent GIB

#GITwitter

A secondary prevention strategy for GIB in LVAD

Danazol, Octreotide, Thalidomide Tamoxifen, Bevacizumab have been studied in retrospective studies.

Thalidomide may prevent GIB better than Danazol & Octreotide.

Be cautious with the side-effect profile of these meds.

The proposed mechanism for these medications are as follows:

Thanks to @WaqasTahir for this incredible design of pathophysiology.

Bevacizumab and Tamoxifen have also be used in 2dry prevention and have shown to be beneficial but not included in our analysis.

bit.ly/3dzZsOj

bit.ly/32wRNdo

However, be cautious with the side-effect profile of these drugs

Our patient was started on Omega-3-FA and IV Octreotide.

After 5 days, Hgb stabilized.

Discharged on Danazol & Omega-3-FA, stopped aspirin on discharge, resumed on coumadin

...and VIOLA🎊🎆!! no new episodes of GIB over 6 months!

🔥Summary -1 🔥

✅AVMs are comon cause of GIB in LVAD

✅UBRS can be used to predict GIB in LVAD recipients

Transfusing🩸🏥 to Hb > 7 and for significant bleeds holding a/c and lets say melena: EGD +/- Colo ➡ No Lesion?

🔥Summary-2🔥

➡ Continued Bleed? ➡ Capsule Endoscopy? ➡Angio? ➡Tagged RBC Scan?

✅1⃣ry(Omega-3-FA, ?Digoxin), 2⃣ry (Thalidomide, Octreotide, Danazol,Tamoxifen, Bevacizumab) prevention of GIB

I feel comfortable in diagnosing, treating, and preventing #GIB in patients with #LVAD.

I learned something in this Tweetorial that may change my clinical practice

Many thanks to @ThomasMDas @CardioNerds @karanpdesai @AmitGoyalMD Academy for their feedback and support!