Jordan E Axelrad1, Adam S Faye2, Alberto Pinsino3, Anusorn Thanataveerat4, Barbara Cagliostro3, Marie Finelle T Pineda3, Katherine Ross3, Rosie T Te-Frey3, Lisa Effner3, Arthur R Garan3, Veli K Topkara3, Hiroo Takayama5, Koji Takeda5, Yoshifumi Naka5, Ivonne Ramirez2, Reuben Garcia-Carrasquillo2, Paolo C Colombo3, Tamas Gonda6, Melana Yuzefpolskaya7. 1. Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York; Division of Gastroenterology, Department of Medicine, NYU School of Medicine, New York, New York. 2. Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York. 3. Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York. 4. Department of Biostatistics, Mailman School of Public Health, New York, New York. 5. Department of Surgery, Columbia University Medical Center, New York, New York. 6. Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York. Electronic address: tg2214@cumc.columbia.edu. 7. Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York. Electronic address: my2249@cumc.columbia.edu.
Abstract
BACKGROUND: Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization. METHODS: We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. RESULTS: We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%). CONCLUSIONS: Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.
BACKGROUND: Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization. METHODS: We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. RESULTS: We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%). CONCLUSIONS: Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.