Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: A Case Report and Literature Review

Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: A Case Report and Literature Review Dan Zhao, Shan Yang, Lijing Deng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4609979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Left ventricular assist devices (LVADs) have become increasingly prevalent as a life-prolonging treatment for patients with advanced heart failure. Despite continuous advancements in the field of continuous-flow left ventricular assist devices (CF-LVADs), recipients still face a relatively high incidence of LVAD-related adverse events, with gastrointestinal bleeding (GIB) being one of the most frequent complications. GIB is closely associated with severely impaired quality of life, frequent hospitalizations, need for blood transfusions, and potential mortality in these patients. Furthermore, many patients experience recurrent GIB events, which further exacerbates their discomfort and medical resource utilization. Although various medical and endoscopic treatment strategies exist, evidence regarding their benefits remains largely ambiguous, with all relevant studies based on data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) rather than clinical trials. While current research provides significant insights into the management of adverse events in LVAD recipients, there is a scarcity of effective and validated indicators and methods for predicting post-implantation GIB events. 1. Case Presentation: We report the case of a 36-year-old male patient with a history of chronic heart failure, diagnosed with dilated cardiomyopathy. While awaiting heart transplantation, the patient experienced worsening heart failure and underwent an emergency LVAD implantation. During the postoperative treatment period, the patient experienced recurrent episodes of GIB that could not be controlled by endoscopic interventions. Ultimately, the patient underwent surgical resection of the bleeding intestinal segment by the gastrointestinal surgery team. Following the surgery, the bleeding ceased, and the patient's bowel function recovered successfully. This case report aims to enrich the literature on GIB following LVAD implantation and its management. 2. Conclusion: Gastrointestinal bleeding is a common complication following LVAD implantation, often requiring endoscopic hemostatic treatment. In refractory cases, surgical resection of the affected intestinal segment may be necessary. Moreover, with frequent bleeding episodes, antiplatelet and anticoagulation therapies often need to be discontinued, which in turn increases the risk of life-threatening events. This case highlights the importance of a multidisciplinary approach in managing GIB in LVAD recipients, as well as the need for further research to develop effective strategies for predicting and preventing this complication. continuous-flow left ventricular assist device gastrointestinal bleeding anticoagulation surgical resection Figures Figure 1 Introduction Continuous-flow left ventricular assist devices (CF-LVADs) are associated with a range of complications, including gastrointestinal (GI) bleeding, which current research suggests is primarily due to the formation of arteriovenous malformations (AVMs). Frequent episodes of GI bleeding often lead to the discontinuation of antiplatelet and anticoagulation therapies, increasing the risk of life-threatening events. Literature reports that 18–40% of patients with CF-LVADs experience bleeding, with AVMs being the primary cause. These malformations are difficult to control and compel many patients to discontinue necessary antiplatelet and anticoagulation treatments. Small bowel lesions are common in this population, frequently necessitating small bowel endoscopy for thorough evaluation. In refractory cases, empiric medications with potential preventive effects may be administered to prevent further GI bleeding. These medications include octreotide, thalidomide, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based therapies, desmopressin, and bevacizumab. However, the efficacy of these medications has not been validated in clinical trials, and there is a lack of specific implementation protocols across medical centers. We report a case of severe early postoperative intestinal bleeding following LVAD implantation at our center, which ultimately required partial colectomy. In this case report, we retrospectively analyze the patient's diagnostic and treatment process for intestinal bleeding. Furthermore, we emphasize the importance of physicians remaining vigilant in recognizing and addressing the risk of GI bleeding in patients after LVAD implantation. Early recognition and prompt intervention are crucial in managing this potentially life-threatening complication. Case Presentation A 36-year-old male patient with a 10-year history of chronic dilated cardiomyopathy, chronic renal insufficiency, type 2 diabetes mellitus (T2DM), and gout was admitted to our hospital for further management of his heart failure. The patient had been experiencing worsening heart failure symptoms despite optimal medical therapy, requiring repeated hospitalizations at a local hospital. Three years prior to the current admission, he had undergone a preoperative echocardiographic assessment for heart transplantation at our hospital's cardiac surgery department, which revealed an enlarged heart, severe mitral regurgitation, moderate tricuspid regurgitation, moderate pulmonary hypertension, severely reduced left ventricular systolic function with a left ventricular ejection fraction (LVEF) of 27%, reduced right ventricular systolic function with a tricuspid annular plane systolic excursion (TAPSE) of 17 mm, and fractional area change (FAC) of 19%. While awaiting heart transplantation, he continued his previous heart failure treatment. One month before the current admission, the patient experienced sudden syncope without obvious triggers. A cardiac ultrasound at the local hospital showed an LVEF of 25% and low blood pressure (details unknown). A chest CT scan revealed a pulmonary infection. After receiving appropriate treatment, the patient's symptoms slightly improved, with a daily urine output of approximately 2000 ml. For further treatment, he was transferred to our hospital's emergency department and admitted to the cardiac intensive care unit. On admission, the physical examination revealed clear consciousness, chronic illness appearance, no abnormalities in the thorax, symmetrical respiratory movements on both sides, moist rales audible in both lower lungs, enlarged heart borders, regular heart rhythm, systolic murmurs audible at the mitral and tricuspid valves, and edema in all four limbs. A cardiac ultrasound showed massive mitral regurgitation; massive tricuspid regurgitation with a maximum velocity (Vmax) of 4.1 m/s and a pressure gradient (PG) of 68 mmHg, indicating severe pulmonary hypertension; left ventricular (LV) dimension of 80 mm; LVEF of 26%; and FAC of 20%. The patient received relevant treatments and underwent intra-aortic balloon pump (IABP) support on the second day of admission. Although the patient had indications for heart transplantation, his current heart failure was severe, and he could not continue to wait for transplantation. Due to severe heart failure, on the fourth day after admission, he underwent "ventricular assist device implantation, tricuspid valve repair, and temporary pacemaker placement on the heart surface" under general anesthesia with cardiopulmonary bypass in the emergency department. The surgery was successful, and the patient was transferred back to the ICU. Postoperatively, the patient received invasive mechanical ventilation, circulatory support, inotropic agents, diuretics, nitric oxide inhalation, anti-infection, anticoagulation, organ function support, and nutritional support. The patient had poor right heart function, pulmonary hypertension, severe pulmonary infection, and respiratory failure, leading to failure in weaning from the ventilator. He underwent tracheostomy, anti-infection treatment, postural drainage, and bronchoscopy, and was gradually weaned from the ventilator. During the course of the disease, the patient had poor right heart function, liver and kidney dysfunction, and complications such as bloodstream bacterial and fungal infections, intestinal flora imbalance, and acute gout attacks, which were treated accordingly. The patient's organ functions gradually improved, and the infections were gradually controlled, with stable circulation. However, due to abdominal distension and poor intestinal peristalsis, it was difficult to establish enteral nutrition, and full enteral nutrition could not be achieved. On the 23rd day after surgery, the patient suddenly developed bloody fluid and melena in the gastrointestinal decompression, with a volume of about 200 ml. Anticoagulant drugs were immediately discontinued, and treatments such as proton pump inhibitors (PPIs), somatostatin, and other hemostatic medications were administered. Subsequently, the patient passed about 300 ml of melena. Bedside gastrointestinal endoscopy revealed a suspected blood clot measuring approximately 4.5 cm × 1.5 cm in the ascending colon near the hepatic flexure, with a vaguely visible ulcerated base. No obvious active bleeding was observed at the base. The endoscopic diagnosis was multiple colonic ulcers with bleeding. The larger ulcer was closed with metal titanium clips, and relevant drug treatments were continued. However, the patient still experienced repeated episodes of melena, with hemoglobin levels fluctuating between 62–85 g/L. Hemostatic treatments and repeated blood transfusions were administered, with a total of 8.5 units of blood transfused during this period. Ten days later, the patient's bleeding suddenly increased, with melena volumes of 300–500 ml per episode and increased frequency. At the same time, the patient had tachycardia, hypotension, and a progressive decrease in hemoglobin to a minimum of 52 g/L. Hemostatic drugs, 4.5 units of red blood cell suspension, 600 ml of plasma, and anti-shock treatments were administered. An emergency endoscopy was performed, revealing colonic ulcers with bleeding. Circular or longitudinal ulcers measuring 2–4 cm were observed from the beginning of the ascending colon to the transverse colon. Titanium clips were again applied to the larger ulcers and areas of active oozing. An abdominal angiography was performed, showing no abnormalities in the intestinal blood vessels. In the following week, the patient still had intermittent melena, and the hemoglobin level progressively decreased, requiring daily blood transfusions to maintain circulation. During the bleeding period, the patient was kept nil by mouth, and total parenteral nutrition (TPN) was provided for nutritional support. Two additional endoscopic explorations and hemostatic treatments were performed, but the patient continued to have melena, with gradually increasing volumes. A total of 18.5 units of red blood cell suspension and 600 ml of fresh frozen plasma were transfused. A multidisciplinary consultation was conducted, and after repeated assessments by the gastrointestinal surgery department, surgical intervention was considered indicated. Twenty days after the patient's first gastrointestinal bleeding episode, a "right hemicolectomy + intraoperative endoscopic exploration" was performed. Intraoperative findings: No bleeding was observed in the small intestine. An irregular ulcer with a yellow-white base and surrounding mucosal congestion and edema was found 20 cm proximal to the ileocecal valve. It was marked with a silk suture for localization. The colon, rectum, and ileocecal valve: The ileocecal valve appeared lip-shaped, with good opening and closing. Irregular ulcers with rough bases and 4 residual titanium clips were observed from the beginning of the ascending colon to the transverse colon near the hepatic flexure. The distal end of the resected intestine was located in the middle of the transverse colon, and the proximal end was 25 cm from the ileocecal valve. An end-to-side anastomosis was performed using a 25 mm stapler. After the surgery, the resected intestinal segment, measuring approximately 55 cm in length, was examined, revealing multiple ulcers with surrounding mucosal congestion and edema. The surgery was successful, and the patient was transferred back to the ICU for continued monitoring and treatment. The patient no longer experienced melena but developed abdominal distension and high tension. A bedside abdominal radiograph indicated significant intestinal gas distension (insert image). Adjuvant medications for gas evacuation were administered, and a rectal tube was placed for decompression. The patient's intestinal gas distension gradually improved, and enteral nutrition was resumed on the 5th day after surgery. Subsequently, the patient's general condition was fair, with stable vital signs. He was transferred to a general ward for continued treatment and was eventually discharged successfully. During the bleeding process, low-dose warfarin anticoagulation was administered, and coagulation, thromboelastography (TEG), and thrombosis parameters were monitored. The patient was in a hypercoagulable state, and the international normalized ratio (INR) was maintained within the range of 1-1.5 until the day of the surgical operation. Anticoagulation was restarted on the first postoperative day, with warfarin bridged with low-molecular-weight heparin to maintain the INR within the range of 1.2–1.8. The patient's INR was gradually extended to the range of 1.8–2.2 when the condition stabilized and at the time of discharge. Discussion Gastrointestinal bleeding is a major cause of impaired quality of life in patients with contemporary CF-LVADs. Literature reports that the incidence of gastrointestinal bleeding 1–3 years after CF-LVAD implantation ranges from 18–27%. Bleeding can occur in different parts of the gastrointestinal tract, with the vast majority occurring in the upper gastrointestinal tract. In 2022, Carlson et al. conducted a pooled analysis of 1,087 patients, showing that the average time from CF-LVAD implantation to the first gastrointestinal bleeding (GIB) event was 54 days, with 40% of patients experiencing multiple GIB episodes. Therefore, it is crucial to promptly assess the nature, location, and duration of bleeding, with the ultimate goal of achieving favorable survival outcomes. Generally, the main management steps for these patients are: first, temporarily discontinue anticoagulation therapy until active bleeding stops; second, reduce the LVAD speed to the lowest safe value possible; and third, perform endoscopic examinations, as endoscopy is the standard management for GIB based on the suspected source and hemodynamic status. In this case, endoscopic examination confirmed that the bleeding site was in the transverse colon, which is an atypical location compared to previous reports. Moreover, the presence of extensive large ulcers is even more uncommon. The specific location and morphology of the ulcers made it impossible for endoscopy to provide definitive treatment, and the patient's recurrent bleeding prolonged the overall hospital stay and increased complications. Additionally, the long-term low-dose anticoagulation state posed a higher risk of thrombus formation in the LVAD. We suggest that if a patient experiences recurrent bleeding and endoscopic hemostasis fails, particularly when the bleeding ulcers are distributed in a circular or linear pattern, making them difficult to clamp and prone to recurrent formation, a timely assessment by the gastrointestinal surgery department for resection of the bleeding intestinal segment should be considered. After surgery, the patient's INR was maintained at 2-2.5. Although the INR fluctuated due to the influence of related medications, there was no temporal correlation with bleeding. According to the coagulation function tests during treatment, the patient's bleeding was not caused by INR fluctuations but was still considered to be due to poor right heart function and early intestinal ischemia. For patients with high-risk factors such as right heart failure, poor gastrointestinal perfusion, and venous return obstruction, perioperative organ function and perfusion monitoring should be strengthened, with early intervention and management. In the future, we should focus on early assessment of abdominal organ perfusion, including monitoring of intra-abdominal pressure and bladder pressure, and take appropriate measures to ultimately enhance right heart function, reduce intra-abdominal pressure, and improve abdominal perfusion. Additionally, exploring ultrasound monitoring methods for mesenteric blood flow and seeking corresponding biomarkers with indicative and predictive value in clinical treatment management could be pursued. Conclusion The occurrence of gastrointestinal bleeding in CF-LVAD recipients severely impacts prognosis and the disease treatment process, exacerbating patient discomfort and delaying recovery. Early recognition and exploration of prevention strategies are of utmost importance. Summarizing this case and proposing preventive measures: patients with CF-LVADs have a high risk of gastrointestinal bleeding. In the future, the focus should be on obtaining stronger evidence regarding secondary prevention of GIB. Based on this case, it is worth discussing whether the patient's repeated abdominal distension and difficulty in establishing enteral nutrition in the early postoperative period could serve as warning signs for subsequent gastrointestinal bleeding. In future research, it is worth investigating whether we can explore early warning signals for patients developing gastrointestinal bleeding by monitoring intra-abdominal pressure, gastrointestinal blood flow perfusion, and enteral nutrition establishment during the perioperative period, and provide early intervention accordingly. Abbreviations LVADs Left ventricular assist devices CF-LVADs continuous-flow left ventricular assist devices GIB gastrointestinal bleeding AVMs arteriovenous malformations LVEF left ventricular ejection fraction INR international normalized ratio IABP intra-aortic balloon pump T2DM type 2 diabetes mellitus Declarations Acknowledgements None Author contributions LJD and DZ designed and conceptualized the study. MM, DZ and SY did the literature review. DZ collected and analysed the data. LJD and DZ wrote the manuscript. All authors read and approve the final version of the manuscript. Funding None Data availability All data generated and analysed during this study are included in this published article. Ethics approval and consent to participate The study was approved by the Ethics committee of Hainan General Hospital. Consent for publication A written informed consent has been obtained from the patient for publication. Competing interests The authors declare no competing interests. References Guha A, Eshelbrenner CL, Richards DM, Monsour HP. Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review. World J Gastroenterol. 2020;26(20):2550–8. Hafer L, Löffler MM, Berger B, Awad M, Keller T, Foerster K, et al. Gastrointestinal bleeding on continuous-flow left ventricular assist device therapy. ESC Heart Fail. 2023;10:2214–24. Thohan V, Ruiz JN, Bhat G. Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients. World J Gastroenterol. 2017;23(22):3945–53. Takahashi K, Kusakawa I, Miyamoto M, Watanabe K, Nomura N, Sato K, et al. Feasibility and safety of laparoscopic colorectal surgeries for patients with left ventricular assist device. Int J Colorectal Dis. 2019;34:1979–82. Shah S, Mehra MR. Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A comprehensive review. Artif Organs. 2023;47:12–23. Dandamudi S, Sayer G, Alharethi R, Rasmusson B, Alharethi B, Cowger J, et al. Right Heart Failure After Left Ventricular Assist Device Placement Medical and Surgical Management Considerations. Cardiol Clin. 2020;38:227–38. Kormos RL. Bleeding and thrombosis associated with ventricular assist device therapy. J Heart Lung Transpl. 2017;36:1164–73. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4609979","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":325112344,"identity":"2853fedc-6e63-4521-aa1a-77aab63037f9","order_by":0,"name":"Dan Zhao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Zhao","suffix":""},{"id":325112345,"identity":"10e060c7-13e8-4c42-b419-d6fd5602736c","order_by":1,"name":"Shan Yang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Shan","middleName":"","lastName":"Yang","suffix":""},{"id":325112346,"identity":"35fd800f-47a6-44c9-bc74-a26e1e37869f","order_by":2,"name":"Lijing Deng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYDCCAyCiQIKZjYGB8UFCRQ2xWgzAWpgNHpw5RrQWMJNN8mELM2EdfMd7D79gMLBg55Nuv1aR2MDGwN/enYBXi+SZc2kWYIfJnCm7kbhDhkHizNkNeLUY3MgxMwBrkchJu5F4hg3IziWg5f4bhJaCxDZmIrTc4DF+ANGSfoyBKC2SZ3LMGKC2MEsknDnGQ9AvfMfPGH9gqKhLlp+R/vDjj4oaOf72XvxagIBN+g8DQzIDAw84dngIKQcB5g9Awo6Bgf0BMapHwSgYBaNgBAIALKFCkHtJLmEAAAAASUVORK5CYII=","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Lijing","middleName":"","lastName":"Deng","suffix":""}],"badges":[],"createdAt":"2024-06-20 07:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4609979/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4609979/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60617075,"identity":"a22dc3c8-438e-4efd-97aa-a0ecc529fd70","added_by":"auto","created_at":"2024-07-18 20:27:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":219445,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIn the colon, there are multiple ulcers\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4609979/v1/c053074dea3b21cfbccccac6.jpg"},{"id":74449357,"identity":"0bce9a9d-6e76-4e99-8a5e-00e2942004a2","added_by":"auto","created_at":"2025-01-22 11:38:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":551173,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4609979/v1/8526af59-e247-413c-aad5-94d45daa1698.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":" \u003cp\u003eContinuous-flow left ventricular assist devices (CF-LVADs) are associated with a range of complications, including gastrointestinal (GI) bleeding, which current research suggests is primarily due to the formation of arteriovenous malformations (AVMs). Frequent episodes of GI bleeding often lead to the discontinuation of antiplatelet and anticoagulation therapies, increasing the risk of life-threatening events. Literature reports that 18\u0026ndash;40% of patients with CF-LVADs experience bleeding, with AVMs being the primary cause. These malformations are difficult to control and compel many patients to discontinue necessary antiplatelet and anticoagulation treatments. Small bowel lesions are common in this population, frequently necessitating small bowel endoscopy for thorough evaluation. In refractory cases, empiric medications with potential preventive effects may be administered to prevent further GI bleeding. These medications include octreotide, thalidomide, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based therapies, desmopressin, and bevacizumab. However, the efficacy of these medications has not been validated in clinical trials, and there is a lack of specific implementation protocols across medical centers. We report a case of severe early postoperative intestinal bleeding following LVAD implantation at our center, which ultimately required partial colectomy. In this case report, we retrospectively analyze the patient's diagnostic and treatment process for intestinal bleeding. Furthermore, we emphasize the importance of physicians remaining vigilant in recognizing and addressing the risk of GI bleeding in patients after LVAD implantation. Early recognition and prompt intervention are crucial in managing this potentially life-threatening complication.\u003c/p\u003e "},{"header":"Case Presentation","content":" \u003cp\u003eA 36-year-old male patient with a 10-year history of chronic dilated cardiomyopathy, chronic renal insufficiency, type 2 diabetes mellitus (T2DM), and gout was admitted to our hospital for further management of his heart failure. The patient had been experiencing worsening heart failure symptoms despite optimal medical therapy, requiring repeated hospitalizations at a local hospital. Three years prior to the current admission, he had undergone a preoperative echocardiographic assessment for heart transplantation at our hospital's cardiac surgery department, which revealed an enlarged heart, severe mitral regurgitation, moderate tricuspid regurgitation, moderate pulmonary hypertension, severely reduced left ventricular systolic function with a left ventricular ejection fraction (LVEF) of 27%, reduced right ventricular systolic function with a tricuspid annular plane systolic excursion (TAPSE) of 17 mm, and fractional area change (FAC) of 19%. While awaiting heart transplantation, he continued his previous heart failure treatment.\u003c/p\u003e \u003cp\u003eOne month before the current admission, the patient experienced sudden syncope without obvious triggers. A cardiac ultrasound at the local hospital showed an LVEF of 25% and low blood pressure (details unknown). A chest CT scan revealed a pulmonary infection. After receiving appropriate treatment, the patient's symptoms slightly improved, with a daily urine output of approximately 2000 ml. For further treatment, he was transferred to our hospital's emergency department and admitted to the cardiac intensive care unit. On admission, the physical examination revealed clear consciousness, chronic illness appearance, no abnormalities in the thorax, symmetrical respiratory movements on both sides, moist rales audible in both lower lungs, enlarged heart borders, regular heart rhythm, systolic murmurs audible at the mitral and tricuspid valves, and edema in all four limbs. A cardiac ultrasound showed massive mitral regurgitation; massive tricuspid regurgitation with a maximum velocity (Vmax) of 4.1 m/s and a pressure gradient (PG) of 68 mmHg, indicating severe pulmonary hypertension; left ventricular (LV) dimension of 80 mm; LVEF of 26%; and FAC of 20%.\u003c/p\u003e \u003cp\u003eThe patient received relevant treatments and underwent intra-aortic balloon pump (IABP) support on the second day of admission. Although the patient had indications for heart transplantation, his current heart failure was severe, and he could not continue to wait for transplantation. Due to severe heart failure, on the fourth day after admission, he underwent \"ventricular assist device implantation, tricuspid valve repair, and temporary pacemaker placement on the heart surface\" under general anesthesia with cardiopulmonary bypass in the emergency department. The surgery was successful, and the patient was transferred back to the ICU. Postoperatively, the patient received invasive mechanical ventilation, circulatory support, inotropic agents, diuretics, nitric oxide inhalation, anti-infection, anticoagulation, organ function support, and nutritional support. The patient had poor right heart function, pulmonary hypertension, severe pulmonary infection, and respiratory failure, leading to failure in weaning from the ventilator. He underwent tracheostomy, anti-infection treatment, postural drainage, and bronchoscopy, and was gradually weaned from the ventilator. During the course of the disease, the patient had poor right heart function, liver and kidney dysfunction, and complications such as bloodstream bacterial and fungal infections, intestinal flora imbalance, and acute gout attacks, which were treated accordingly. The patient's organ functions gradually improved, and the infections were gradually controlled, with stable circulation. However, due to abdominal distension and poor intestinal peristalsis, it was difficult to establish enteral nutrition, and full enteral nutrition could not be achieved. On the 23rd day after surgery, the patient suddenly developed bloody fluid and melena in the gastrointestinal decompression, with a volume of about 200 ml. Anticoagulant drugs were immediately discontinued, and treatments such as proton pump inhibitors (PPIs), somatostatin, and other hemostatic medications were administered. Subsequently, the patient passed about 300 ml of melena. Bedside gastrointestinal endoscopy revealed a suspected blood clot measuring approximately 4.5 cm \u0026times; 1.5 cm in the ascending colon near the hepatic flexure, with a vaguely visible ulcerated base. No obvious active bleeding was observed at the base. The endoscopic diagnosis was multiple colonic ulcers with bleeding. The larger ulcer was closed with metal titanium clips, and relevant drug treatments were continued. However, the patient still experienced repeated episodes of melena, with hemoglobin levels fluctuating between 62\u0026ndash;85 g/L. Hemostatic treatments and repeated blood transfusions were administered, with a total of 8.5 units of blood transfused during this period. Ten days later, the patient's bleeding suddenly increased, with melena volumes of 300\u0026ndash;500 ml per episode and increased frequency. At the same time, the patient had tachycardia, hypotension, and a progressive decrease in hemoglobin to a minimum of 52 g/L. Hemostatic drugs, 4.5 units of red blood cell suspension, 600 ml of plasma, and anti-shock treatments were administered. An emergency endoscopy was performed, revealing colonic ulcers with bleeding. Circular or longitudinal ulcers measuring 2\u0026ndash;4 cm were observed from the beginning of the ascending colon to the transverse colon. Titanium clips were again applied to the larger ulcers and areas of active oozing. An abdominal angiography was performed, showing no abnormalities in the intestinal blood vessels.\u003c/p\u003e \u003cp\u003eIn the following week, the patient still had intermittent melena, and the hemoglobin level progressively decreased, requiring daily blood transfusions to maintain circulation. During the bleeding period, the patient was kept nil by mouth, and total parenteral nutrition (TPN) was provided for nutritional support. Two additional endoscopic explorations and hemostatic treatments were performed, but the patient continued to have melena, with gradually increasing volumes. A total of 18.5 units of red blood cell suspension and 600 ml of fresh frozen plasma were transfused. A multidisciplinary consultation was conducted, and after repeated assessments by the gastrointestinal surgery department, surgical intervention was considered indicated. Twenty days after the patient's first gastrointestinal bleeding episode, a \"right hemicolectomy\u0026thinsp;+\u0026thinsp;intraoperative endoscopic exploration\" was performed. Intraoperative findings: No bleeding was observed in the small intestine. An irregular ulcer with a yellow-white base and surrounding mucosal congestion and edema was found 20 cm proximal to the ileocecal valve. It was marked with a silk suture for localization. The colon, rectum, and ileocecal valve: The ileocecal valve appeared lip-shaped, with good opening and closing. Irregular ulcers with rough bases and 4 residual titanium clips were observed from the beginning of the ascending colon to the transverse colon near the hepatic flexure. The distal end of the resected intestine was located in the middle of the transverse colon, and the proximal end was 25 cm from the ileocecal valve. An end-to-side anastomosis was performed using a 25 mm stapler.\u003c/p\u003e \u003cp\u003eAfter the surgery, the resected intestinal segment, measuring approximately 55 cm in length, was examined, revealing multiple ulcers with surrounding mucosal congestion and edema. The surgery was successful, and the patient was transferred back to the ICU for continued monitoring and treatment. The patient no longer experienced melena but developed abdominal distension and high tension. A bedside abdominal radiograph indicated significant intestinal gas distension (insert image). Adjuvant medications for gas evacuation were administered, and a rectal tube was placed for decompression. The patient's intestinal gas distension gradually improved, and enteral nutrition was resumed on the 5th day after surgery. Subsequently, the patient's general condition was fair, with stable vital signs. He was transferred to a general ward for continued treatment and was eventually discharged successfully. During the bleeding process, low-dose warfarin anticoagulation was administered, and coagulation, thromboelastography (TEG), and thrombosis parameters were monitored. The patient was in a hypercoagulable state, and the international normalized ratio (INR) was maintained within the range of 1-1.5 until the day of the surgical operation. Anticoagulation was restarted on the first postoperative day, with warfarin bridged with low-molecular-weight heparin to maintain the INR within the range of 1.2\u0026ndash;1.8. The patient's INR was gradually extended to the range of 1.8\u0026ndash;2.2 when the condition stabilized and at the time of discharge.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eGastrointestinal bleeding is a major cause of impaired quality of life in patients with contemporary CF-LVADs. Literature reports that the incidence of gastrointestinal bleeding 1\u0026ndash;3 years after CF-LVAD implantation ranges from 18\u0026ndash;27%. Bleeding can occur in different parts of the gastrointestinal tract, with the vast majority occurring in the upper gastrointestinal tract. In 2022, Carlson et al. conducted a pooled analysis of 1,087 patients, showing that the average time from CF-LVAD implantation to the first gastrointestinal bleeding (GIB) event was 54 days, with 40% of patients experiencing multiple GIB episodes. Therefore, it is crucial to promptly assess the nature, location, and duration of bleeding, with the ultimate goal of achieving favorable survival outcomes. Generally, the main management steps for these patients are: first, temporarily discontinue anticoagulation therapy until active bleeding stops; second, reduce the LVAD speed to the lowest safe value possible; and third, perform endoscopic examinations, as endoscopy is the standard management for GIB based on the suspected source and hemodynamic status. In this case, endoscopic examination confirmed that the bleeding site was in the transverse colon, which is an atypical location compared to previous reports. Moreover, the presence of extensive large ulcers is even more uncommon. The specific location and morphology of the ulcers made it impossible for endoscopy to provide definitive treatment, and the patient's recurrent bleeding prolonged the overall hospital stay and increased complications. Additionally, the long-term low-dose anticoagulation state posed a higher risk of thrombus formation in the LVAD.\u003c/p\u003e \u003cp\u003eWe suggest that if a patient experiences recurrent bleeding and endoscopic hemostasis fails, particularly when the bleeding ulcers are distributed in a circular or linear pattern, making them difficult to clamp and prone to recurrent formation, a timely assessment by the gastrointestinal surgery department for resection of the bleeding intestinal segment should be considered. After surgery, the patient's INR was maintained at 2-2.5. Although the INR fluctuated due to the influence of related medications, there was no temporal correlation with bleeding. According to the coagulation function tests during treatment, the patient's bleeding was not caused by INR fluctuations but was still considered to be due to poor right heart function and early intestinal ischemia. For patients with high-risk factors such as right heart failure, poor gastrointestinal perfusion, and venous return obstruction, perioperative organ function and perfusion monitoring should be strengthened, with early intervention and management. In the future, we should focus on early assessment of abdominal organ perfusion, including monitoring of intra-abdominal pressure and bladder pressure, and take appropriate measures to ultimately enhance right heart function, reduce intra-abdominal pressure, and improve abdominal perfusion. Additionally, exploring ultrasound monitoring methods for mesenteric blood flow and seeking corresponding biomarkers with indicative and predictive value in clinical treatment management could be pursued.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThe occurrence of gastrointestinal bleeding in CF-LVAD recipients severely impacts prognosis and the disease treatment process, exacerbating patient discomfort and delaying recovery. Early recognition and exploration of prevention strategies are of utmost importance. Summarizing this case and proposing preventive measures: patients with CF-LVADs have a high risk of gastrointestinal bleeding. In the future, the focus should be on obtaining stronger evidence regarding secondary prevention of GIB. Based on this case, it is worth discussing whether the patient's repeated abdominal distension and difficulty in establishing enteral nutrition in the early postoperative period could serve as warning signs for subsequent gastrointestinal bleeding. In future research, it is worth investigating whether we can explore early warning signals for patients developing gastrointestinal bleeding by monitoring intra-abdominal pressure, gastrointestinal blood flow perfusion, and enteral nutrition establishment during the perioperative period, and provide early intervention accordingly.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eLVADs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Left ventricular assist devices\u003c/p\u003e\n\u003cp\u003eCF-LVADs \u0026nbsp; \u0026nbsp; continuous-flow left ventricular assist devices\u003c/p\u003e\n\u003cp\u003eGIB \u0026nbsp; \u0026nbsp; \u0026nbsp; gastrointestinal bleeding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAVMs \u0026nbsp; \u0026nbsp; arteriovenous malformations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLVEF \u0026nbsp; \u0026nbsp; \u0026nbsp;left ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003eINR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;international normalized ratio\u003c/p\u003e\n\u003cp\u003eIABP \u0026nbsp; \u0026nbsp; \u0026nbsp; intra-aortic balloon pump\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eT2DM \u0026nbsp; \u0026nbsp;type 2 diabetes mellitus\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLJD and DZ designed and conceptualized the study. MM, DZ and SY did the literature review. DZ collected and analysed the data. LJD and DZ \u0026nbsp;wrote the manuscript. All authors read and approve the final version of \u0026nbsp;the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics committee of Hainan General Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written informed consent has been obtained from the patient for\u0026nbsp;\u003c/p\u003e\n\u003cp\u003epublication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuha A, Eshelbrenner CL, Richards DM, Monsour HP. Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review. World J Gastroenterol. 2020;26(20):2550\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHafer L, L\u0026ouml;ffler MM, Berger B, Awad M, Keller T, Foerster K, et al. Gastrointestinal bleeding on continuous-flow left ventricular assist device therapy. ESC Heart Fail. 2023;10:2214\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThohan V, Ruiz JN, Bhat G. Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients. World J Gastroenterol. 2017;23(22):3945\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakahashi K, Kusakawa I, Miyamoto M, Watanabe K, Nomura N, Sato K, et al. Feasibility and safety of laparoscopic colorectal surgeries for patients with left ventricular assist device. Int J Colorectal Dis. 2019;34:1979\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah S, Mehra MR. Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A comprehensive review. Artif Organs. 2023;47:12\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDandamudi S, Sayer G, Alharethi R, Rasmusson B, Alharethi B, Cowger J, et al. Right Heart Failure After Left Ventricular Assist Device Placement Medical and Surgical Management Considerations. Cardiol Clin. 2020;38:227\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKormos RL. Bleeding and thrombosis associated with ventricular assist device therapy. J Heart Lung Transpl. 2017;36:1164\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"continuous-flow left ventricular assist device, gastrointestinal bleeding, anticoagulation, surgical resection","lastPublishedDoi":"10.21203/rs.3.rs-4609979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4609979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Left ventricular assist devices (LVADs) have become increasingly prevalent as a life-prolonging treatment for patients with advanced heart failure. Despite continuous advancements in the field of continuous-flow left ventricular assist devices (CF-LVADs), recipients still face a relatively high incidence of LVAD-related adverse events, with gastrointestinal bleeding (GIB) being one of the most frequent complications. GIB is closely associated with severely impaired quality of life, frequent hospitalizations, need for blood transfusions, and potential mortality in these patients. Furthermore, many patients experience recurrent GIB events, which further exacerbates their discomfort and medical resource utilization. Although various medical and endoscopic treatment strategies exist, evidence regarding their benefits remains largely ambiguous, with all relevant studies based on data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) rather than clinical trials. While current research provides significant insights into the management of adverse events in LVAD recipients, there is a scarcity of effective and validated indicators and methods for predicting post-implantation GIB events.\u003c/p\u003e \u003cp\u003e1. Case Presentation: We report the case of a 36-year-old male patient with a history of chronic heart failure, diagnosed with dilated cardiomyopathy. While awaiting heart transplantation, the patient experienced worsening heart failure and underwent an emergency LVAD implantation. During the postoperative treatment period, the patient experienced recurrent episodes of GIB that could not be controlled by endoscopic interventions. Ultimately, the patient underwent surgical resection of the bleeding intestinal segment by the gastrointestinal surgery team. Following the surgery, the bleeding ceased, and the patient's bowel function recovered successfully. This case report aims to enrich the literature on GIB following LVAD implantation and its management.\u003c/p\u003e \u003cp\u003e2. Conclusion: Gastrointestinal bleeding is a common complication following LVAD implantation, often requiring endoscopic hemostatic treatment. In refractory cases, surgical resection of the affected intestinal segment may be necessary. Moreover, with frequent bleeding episodes, antiplatelet and anticoagulation therapies often need to be discontinued, which in turn increases the risk of life-threatening events. This case highlights the importance of a multidisciplinary approach in managing GIB in LVAD recipients, as well as the need for further research to develop effective strategies for predicting and preventing this complication.\u003c/p\u003e","manuscriptTitle":"Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:27:32","doi":"10.21203/rs.3.rs-4609979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d973f20-de0e-4e3f-a07b-42827de10070","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-22T11:38:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:27:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4609979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4609979","identity":"rs-4609979","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}