#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 💩 Image
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 https://bit.ly/32sPo3e
The etiology and pathophysiology of #GIB in LVAD patients could be multifactorial as follows: https://bit.ly/3drB3ue
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 ImageImage
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 ImageImage
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) https://bit.ly/3n30O7l
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 Image
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 https://bit.ly/3n30O7l
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. Image
The proposed mechanism for these medications are as follows:

Thanks to @WaqasTahir for this incredible design of pathophysiology. Image
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!

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More from @DeveshRaiMD

23 Feb
When do you typically discharge your patients post-TAVR?

Check out the 🧵 below for a #tweetorial about same-day discharge following #TAVR!

@tavrkapadia @Edwards_TAVR @TAVRBot @cardioPCImom @SripalBangalore @SrihariNaiduMD @Pooh_Velagapudi @ehj_ed @DLBHATTMD @JPDeptaMD
After this thread 🧵, you'll:

✅Recognize common complications🩺 after TAVR

✅Understand the feasibility of Same-Day Discharge (#SDD) and predictors of Next Day Discharge (NDD) after TAVR.

@CCIJournal #TAVR @WaqasTahir
I feel comfortable🙂 identifying patients who can be discharged🚑 on the same-day after TAVR?
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