Clin Endosc.  2017 Nov;50(6):598-601. 10.5946/ce.2017.024.

Combined Endoscopic and Surgical Treatment of Severe Gastrointestinal Bleeding in a Patient with Heart Assist Device under Therapeutic Anticoagulation

Affiliations
  • 1Department of Gastroenterology and Gastrointestinal Oncology, Göttingen University Hospital, Göttingen, Germany. edriswedi@gmail.com
  • 2Department of Gastroenterology, Nouvel Hôpital Civil, University Hospitals, Strasbourg, France.
  • 3Medicine Department, Exploration and Digestive Endoscopy Unit, Public Hospital Establishment Mohamed Boudiaf, El Khroub, Algeria.
  • 4Department of Surgery, Nouvel Hôpital Civil and IHU Strasbourg, University Hospitals, Strasbourg, France.
  • 5Hepatobiliary Unit, Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, Italy.

Abstract

Gastrointestinal (GI) bleeding is a common complication after heart assist device placement. Reasons for bleeding are multifactorial. Endoscopic therapy is the treatment of choice, whereas invasive procedures are avoided in these critically ill patients. We present the case of a 65-year-old male patient experiencing severe GI bleeding after left ventricular assist device (LVAD) and right ventricular assist device (RVAD) placement with therapeutic anticoagulation. Endoscopically, multiple gastric bleeding sources were found but could not be treated effectively due to a large blood clot. A combined endoscopic and surgical treatment was initiated, including gastrotomy for blood clot removal, surgical transgastric suturing, endoscopic over-the-scope clip (OTSC) placement and hemospray application. Postoperative endoscopic visualization showed effective bleeding control. The patient unfortunately died due to causes unrelated to the treatment. This case shows that a minimal invasive combination of endoscopic and surgical techniques can be an alternative treatment for severe upper GI bleeding in critically ill and anticoagulated patients.

Keyword

Heart assist devices; Gastrointestinal hemorrhage; Combined endoscopic and surgical treatment; Over-the-scope-clip; Hemospray

MeSH Terms

Aged
Critical Illness
Gastrointestinal Hemorrhage
Heart*
Heart-Assist Devices
Hemorrhage*
Humans
Male

Figure

  • Fig. 1. 10 cm measuring bulky blood clot (retrovision).

  • Fig. 2. Surgeons head seen from the gastroscope through an anterior gastrotomy.

  • Fig. 3. Bleeding site (surgical suturing).

  • Fig. 4. Bleeding site (over-the-scope clip placement).

  • Fig. 5. Hemospray application.


Reference

1. Harvey L, Holley CT, John R. Gastrointestinal bleed after left ventricular assist device implantation: incidence, management, and prevention. Ann Cardiothorac Surg. 2014; 3:475–479.
2. Islam S, Cevik C, Madonna R, et al. Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series. Clin Cardiol. 2013; 36:190–200.
Article
3. Crow S, John R, Boyle A, et al. Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg. 2009; 137:208–215.
Article
4. Letsou GV, Shah N, Gregoric ID, Myers TJ, Delgado R, Frazier OH. Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device. J Heart Lung Transplant. 2005; 24:105–109.
Article
5. Aggarwal A, Pant R, Kumar S, et al. Incidence and management of gastrointestinal bleeding with continuous flow assist devices. Ann Thorac Surg. 2012; 93:1534–1540.
Article
6. Draper KV, Huang RJ, Gerson LB. GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis. Gastrointest Endosc. 2014; 80:435–446.e1.
Article
7. Kushnir VM, Sharma S, Ewald GA, et al. Evaluation of GI bleeding after implantation of left ventricular assist device. Gastrointest Endosc. 2012; 75:973–979.
Article
8. John R. Current axial-flow devices--the HeartMate II and Jarvik 2000 left ventricular assist devices. Semin Thorac Cardiovasc Surg. 2008; 20:264–272.
Article
9. 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 therapy. Ann Thorac Surg. 2008; 86:1227–1234. ; discussion 1234-1235.
Article
10. Bhatt DL, Cryer BL, Contant CF, et al. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med. 2010; 363:1909–1917.
Article
11. Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. 2002; 346:2033–2038.
Article
12. Holster IL, Kuipers EJ, Tjwa ET. Hemospray in the treatment of upper gastrointestinal hemorrhage in patients on antithrombotic therapy. Endoscopy. 2013; 45:63–66.
Article
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