ARTICLE IN PRESS doi:10.1510/icvts.2010.241703
Interactive CardioVascular and Thoracic Surgery 11 (2010) 612–613 www.icvts.org
Proposal for bail-out procedures - Assisted circulation
Surgical management of unusual gastrointestinal bleeding and a left ventricular assist device Vance Smitha, Benjamin Sunb, David Lindseya, Michael S. Firstenbergb,* a Department of General Surgery, The Ohio State University Medical Center, Columbus, OH, USA Division of Cardiothoracic Surgery, The Ohio State University Medical Center, N817 Doan Hall, 410 W 10th Avenue, Columbus, OH 43210, USA
b
Received 26 April 2010; received in revised form 7 August 2010; accepted 16 August 2010
Abstract There is growing evidence that patients treated with continuous flow ventricular assist devices are at increased risk for bleeding complications beyond what would be expected for those requiring anti-coagulation therapy. However, the management of these patients is typically medical. We present a case of unusual gastrointestinal bleeding successfully managed with surgical intervention in a patient with a Heartmate II ventricular assist device. 䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Bleeding (gastro-intestinal); Mechanical assist device; Congestive heart failure; Complications
1. Introduction Left ventricular assist devices (LVAD) have revolutionized the management of patients with end-stage heart failure w1, 2x. Despite advances in continuous flow technology, patients require systemic anti-coagulation, and are prone to bleeding-related complications. The risk of gastrointestinal (GI) bleeding is well-documented w3x and has been associated with an acquired vonWillebrands disorder and arterio-venous malformations w4x. Other causes must be considered. We present an unusual case of GI bleeding in a patient supported with a Heartmate II LVAD. 2. Case Our patient was a 71-year-old female who underwent uncomplicated implantation of a Heartmate II LVAD in March 2007 for an end-stage ischemic cardiomyopathy. She had undergone an antrectomy and Billroth II reconstruction for a bleeding gastric ulcer in 1965. It was unclear if she had a concomitant anti-ulcer procedure (i.e. vagotomy). Her anti-coagulation management consisted of aspirin (325 mg daily), coumadin wtarget international normalized ratio (INR)s2.0–2.5x, and lansoprazole (30 mg daily). The patient presented on September 2009 with fatigue and melena. At the time of admission, her hemoglobin was 6.7 mgydl, INR was 2.1, partial thromboplastin time (PPT) was 33 seconds, and platelet count was 236,000. Two previous evaluations for acquired vonWillebrand disease consisting of risotocetic cofactor and vonWillebrand factor activity and multimeric analysis (as part of a separate *Corresponding author. Tel.: q1 614 293 5502; fax: q1 614 293 4267. E-mail address:
[email protected] (M.S. Firstenberg). 䊚 2010 Published by European Association for Cardio-Thoracic Surgery
ongoing screening activity in our patients with LVADs) were unremarkable. Platelet function testing was not performed. Upper endoscopy revealed a bleeding marginal ulcer at the gastrojejunostomy anastomosis. This was initially treated with 1:1,000,000 concentration of epinephrine injections and clipped. Her coagulopathy was corrected with multiple blood (eight units), fresh frozen plasma (10 units), and platelet transfusions (four units). Despite an INRs1.3, over the next 36 hours, her hemoglobin count continued to decline. At repeat endoscopy showed continued bleeding from the injected and clipped ulcer bed. It was determined that further endoscopic management would not be successful in this case. Therefore, she was taken for surgical exploration. Antibiotic prophylaxis consisted of 1 g ertapenem sodium (Merck, Whitehouse Station, NJ, USA) pre- and 24 hours postoperatively. Chloraprep (Carefusion Inc, Leawood, KS, USA), a 2% chlorohexidine and 70% isopropyl alcohol based solution was used to prepare the abdomen. The driveline, which exited the skin in the right lower quadrant, was isolated using an Ioban antimicrobial drape (3M, St Paul, MN, USA). A upper midline laparotomy was performed, fortunately the intra-abdominal adhesions were minimal, and a gastrotomy created along the body of the stomach superior to the Billroth II anastomosis. As the LVAD was entirely preperitoneal, the pocket was not encountered w5x. The stomach was opened and a 1.5-cm ulcer was identified along the posterior anastomoses. There was continuous arterial bleeding from the center of the ulcer (Fig. 1). The endoclips were removed, the bleeding vessel was ligated, and the ulcer resected. Primarily the defect was closed. Placement of the LVAD limited evaluation of the esophagus and the performing of a truncal vagotomy. A heparin drip was
ARTICLE IN PRESS V. Smith et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 612–613
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Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art Best Evidence Topic
The ulcer recurrence rate following truncal vagotomy and antrectomy is 2–5% w6x. While lifelong H2-antagonists or proton pump inhibitors decrease the incidence of ulcer recurrence, bleeding can still occur w7x. Recurrent ulcers can be multi-factorial and complex. Patients with GI bleeding secondary ulcers should undergo prompt endoscopic evaluation and definitive therapy to prevent mortality from hemorrhage. GI bleeding after LVAD placement is a well-known, but poorly described problem occurring in 15% of patients w1x. The etiology hypothesized is that in addition to the need for anti-coagulation, non-pulsatile devices may precipitate
ESCVS Article
3. Discussion
w1x John R, Kamdar F, Liao K, Colvin-Adams M, Boyle A, Joyce L. Improved survival and decreasing incidence of adverse events with the Heartmate II left ventricular assist device as bridge-to-transplant. Ann Thorac Surg 2008;86:1227–1235. w2x Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, Sun B, Tatooles AJ, Delgado RM 3rd, Long JW, Wozniak TC, Ghumman W, Farrar DJ, Frazier OH, HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241–2251. w3x Miller LW, Pagaini FD, Russell SD, John R, Boyle AJ, Aaronson KD, Conte JV, Naka Y, Mancini D, Delgado RM, Macgillivray TE, Farrar DJ, Frazer OH. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 2007;357:885–896. w4x Letsou GV, Shah N, Gregoric ID, Nyers TJ, Delgado R, Frazier OH. Gastrointestinal bleeding from ateriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device. J Heart Lung Transplant 2005;24:105–109. w5x McCarthy PM, Wang N, Vargo R. Preperitoneal insertion of the HeartMate 1000 IP implantable left ventricular assist device. Ann Thorac Surg 1994;57:634–637. w6x Cameron JL. Current surgical therapy, eight edition. Philadelphia: Elsevier-Mosby, 2004;71–76. w7x Sung LL, Barkun A, Kuioers EJ, Mossner J, Jensen DM, Stuart R, Lau JY, Ahlbom H, Kihamn J, Lind T. Intravenous esomeprazole for the prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med 2009;150:455–464. w8x Warkenin TE, Moore JC, Anand SS, Lonn EM, Morgan DG. Gastrointestinal bleeding, angiodysplasia, cardiovascular disease, and acquired vonWillebrand syndrome. Tranfus Med Rev 2003;17:272–286.
Institutional Report
started 24 hours postoperatively. By postoperative day (POD) 5 the patient’s diet was advanced and coumadin was restarted. She was discharged for rehabilitation on POD 9. The final pathology of the ulcer showed acute on chronic inflammation without evidence of Helicobacter pylori or malignancy. Seven months postsurgery, she is doing well, her anti-coagulation is back to baseline, and she has had no further bleeding episodes.
References
Protocol
Fig. 1. Gastrostomy at time of laparotomy revealed a bleeding ulcer along the posterior gastrojejunostomy anastomosis.
Work in Progress Report
GI bleeding is a known complication of anti-coagulation in general and in patients requiring LVAD therapy. A comprehensive team approach is necessary to evaluate all cases for potential causes and medical, endoscopic, or surgical treatment options. Definitive therapy should be pursued promptly before the onset of complications from massive blood transfusion, right heart failure from volume overload, or hypovolemic shock, in what are otherwise complex patients.
New Ideas
4. Conclusion
Editorial
an acquired vonWillebrands disease – similar to bleeding associated with aortic stenosis (Heydes Syndrome) w8x. Reliable management protocols are lacking and management is typically reduction in anti-coagulation or antiplatelet intensity. More aggressive bleeding, such as in our patient, may require surgical treatment.
Nomenclature Historical Pages Brief Case Report Communication
