Resource utilization and hospital readmission associated with gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices

  • Anthony P. Carnicelli
  • Anjali Thakkar
  • David J. Deicicchi
  • Andrew C. Storm
  • Jessica Rimsans
  • Jean M. Connors
  • Mandeep R. Mehra
  • John D. Groarke
  • Michael M. GivertzEmail author


Gastrointestinal bleeding (GIB) occurs in up to 40% of patients with continuous-flow (CF) left ventricular assist devices (LVADs). We sought to identify targets to improve hospital resource utilization and decrease readmissions after GIB. We performed a single-center, retrospective analysis of LVAD-associated GIB resulting in hospital admission between July 2011 and April 2014. Follow-up data were collected through March 2015. We analyzed 57 admissions for GIB in 23 patients. One or more diagnostic imaging study was performed in 47% of admissions, with a definite or probable source of GIB identified in 23%. A total of 76 endoscopies were performed (≥ 1 endoscopy in 79% of admissions, ≥ 2 in 42%). Definite or probable bleeding sources were identified in 25% and 12% of endoscopies, respectively. Patients who underwent multiple endoscopies were no more likely to have a bleeding source identified (OR 1.48; 95% CI 0.50–4.32; p = 0.59) and had longer hospital stays (11.1 vs. 7.8 days, p < 0.02). Readmission rates for GIB at 30 and 90 days were 33% and 53%, respectively. A decrease in antiplatelet regimen at discharge was associated with lower rate of readmission for GIB (OR 0.16; 95% CI 0.03–0.82; p = 0.03) or any cause (OR 0.21; 95% CI 0.05–0.85; p = 0.04) at 30 and 90 days. GIB in patients with CF-LVADs is associated with significant in-hospital resource utilization and high rates of readmission. Imaging and endoscopy are common, but have low diagnostic yield and infrequently result in successful intervention. Strategies to reduce resource utilization and prevent readmission are warranted.


Left ventricular assist device Gastrointestinal bleeding Resource utilization Readmission 



Continuous flow left ventricular assist device


Confidence interval


Computed tomography




Fresh frozen plasma


Gastrointestinal bleeding


HeartWare ventricular assist device


Intensive care unit


International normalized ratio


Interquartile range


Odds ratio


Pulsatile flow


Time in therapeutic range


Video capsule endoscopy


Compliance with ethical standards

Conflict of interest

Dr. Mehra reports non-financial support and other from Abbott, Inc (previously St. Jude Medical), personal fees from Medtronic, personal fees from Janssen (Johnson and Johnson), personal fees from Mesoblast, personal fees from Portola, personal fees from NuPulseCV, Inc, personal fees from Bayer, outside the submitted work. All other authors report no conflicts of interest relative to above manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was not required for this study given the retrospective, observational study design.

Supplementary material

11239_2018_1781_MOESM1_ESM.docx (74 kb)
Supplementary material 1 (DOCX 73 KB)


  1. 1.
    Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume ED, Myers SL, Miller MA, Baldwin JT, Young JB (2015) Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant 34:1495–1504CrossRefPubMedCentralGoogle Scholar
  2. 2.
    Crow S, John R, Boyle A, Shumway S, Liao K, Colvin-Adams M, Toninato C, Missov E, Pritzker M, Martin C, Garry D, Thomas W, Joyce L (2009) Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg 137:208–215CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Aggarwal A, Pant R, Kumar S, Sharma P, Gallagher C, Tatooles AJ, Pappas PS, Bhat G (2012) Incidence and management of gastrointestinal bleeding with continuous flow assist devices. Ann Thorac Surg 93:1534–1540CrossRefPubMedCentralGoogle Scholar
  4. 4.
    Draper KV, Huang RJ, Gerson LB (2014) GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis. Gastrointest Endosc 80:435–446.e1CrossRefPubMedCentralGoogle Scholar
  5. 5.
    Miller LW, Guglin M, Rogers J (2013) Cost of ventricular assist devices: can we afford the progress? Circulation 127:743–748CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Long EF, Swain GW, Mangi AA (2014) Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure. Circ Heart Fail 7:470–478CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Joy PS, Kumar G, Guddati AK, Bhama JK, Cadaret LM (2016) Risk factors and outcomes of gastrointestinal bleeding in left ventricular assist device recipients. Am J Cardiol 117:240–244CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Hasin T, Marmor Y, Kremers W, Topilsky Y, Severson CJ, Schirger JA, Boilson BA, Clavell AL, Rodeheffer RJ, Frantz RP, Edwards BS, Pereira NL, Stulak JM, Joyce L, Daly R, Park SJ, Kushwaha SS (2013) Readmissions after implantation of axial flow left ventricular assist device. J Am Coll Cardiol 61:153–163CrossRefPubMedCentralGoogle Scholar
  9. 9.
    Akhter SA, Badami A, Murray M, Kohmoto T, Lozonschi L, Osaki S, Lushaj EB (2015) Hospital readmissions after continuous-flow left ventricular assist device implantation: incidence, causes, and cost analysis. Ann Thorac Surg 100:884–889CrossRefPubMedCentralGoogle Scholar
  10. 10.
    Morgan JA, Paone G, Nemeh HW, Henry SE, Patel R, Vavra J, Williams CT, Lanfear DE, Tita C, Brewer RJ (2012) Gastrointestinal bleeding with the HeartMate II left ventricular assist device. J Heart Lung Transplant 31:715–718CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Smedira NG, Hoercher KJ, Lima B, Mountis MM, Starling RC, Thuita L, Schmuhl DM, Blackstone EH (2013) Unplanned hospital readmissions after HeartMate II implantation: frequency, risk factors, and impact on resource use and survival. JACC Heart Fail 1:31–39CrossRefPubMedCentralGoogle Scholar
  12. 12.
    Stone ML, LaPar DJ, Benrashid E, Scalzo DC, Ailawadi G, Kron IL, Bergin JD, Blank RS, Kern JA (2015) Ventricular assist devices and increased blood product utilization for cardiac transplantation. J Card Surg 30:194–200CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Eckman PM, John R (2012) Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation 125:3038–3047CrossRefPubMedCentralGoogle Scholar
  14. 14.
    Harris LA, Hansel SL, Rajan E, Srivathsan K, Rea R, Crowell MD, Fleischer DE, Pasha SF, Gurudu SR, Heigh RI, Shiff AD, Post JK, Leighton JA (2013) Capsule endoscopy in patients with implantable electromedical devices is safe. Gastroenterol Res Pract 2013:959234CrossRefPubMedCentralGoogle Scholar
  15. 15.
    Shrode CW, Draper KV, Huang RJ, Kennedy JL, Godsey AC, Morrison CC, Shami VM, Wang AY, Kern JA, Bergin JD, Ailawadi G, Banerjee D, Gerson LB, Sauer BG (2014) Significantly higher rates of gastrointestinal bleeding and thromboembolic events with left ventricular assist devices. Clin Gastroenterol Hepatol 12:1461–1467CrossRefPubMedCentralGoogle Scholar
  16. 16.
    Singh G, Albeldawi M, Kalra SS, Mehta PP, Lopez R, Vargo JJ (2015) Features of patients with gastrointestinal bleeding after implantation of ventricular assist devices. Clin Gastroenterol Hepatol 13:107–114.e1CrossRefPubMedCentralGoogle Scholar
  17. 17.
    Dakik HK, McGhan AA, Chiu ST, Patel CB, Milano CA, Rogers JG, Chow SC, Wild DM (2016) The diagnostic yield of repeated endoscopic evaluation in patients with gastrointestinal bleeding and left ventricular assist devices. Dig Dis Sci 61:1603–1610CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Guha A, Eshelbrenner CL, Richards DM, Monsour HP Jr (2015) Gastrointestinal bleeding after continuous-flow left ventricular device implantation: review of pathophysiology and management. Methodist Debakey Cardiovasc J 11:24–27CrossRefPubMedCentralGoogle Scholar
  19. 19.
    Fisher M, Loscalzo J (2011) The perils of combination antithrombotic therapy and potential resolutions. Circulation 123:232–235CrossRefPubMedCentralGoogle Scholar
  20. 20.
    Menon AK, Gotzenich A, Sassmannshausen H, Haushofer M, Autschbach R, Spillner JW (2012) Low stroke rate and few thrombo-embolic events after HeartMate II implantation under mild anticoagulation. Eur J Cardiothorac Surg 42:319–323 (discussion 323)CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Litzler PY, Smail H, Barbay V, Nafeh-Bizet C, Bouchart F, Baste JM, Abriou C, Bessou JP (2014) Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience. Eur J Cardiothorac Surg 45:55–59 (discussion 59–60)CrossRefPubMedCentralGoogle Scholar
  22. 22.
    Stulak JM, Lee D, Haft JW, Romano MA, Cowger JA, Park SJ, Aaronson KD, Pagani FD (2014) Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant 33:60–64CrossRefPubMedCentralGoogle Scholar
  23. 23.
    Draper K, Kale P, Martin B, Cordero K, Ha R, Banerjee D (2015) Thalidomide for treatment of gastrointestinal angiodysplasia in patients with left ventricular assist devices: case series and treatment protocol. J Heart Lung Transplant 34:132–134CrossRefPubMedCentralGoogle Scholar
  24. 24.
    Schettle SD, Pruthi RK, Pereira NL (2014) Continuous-flow left ventricular assist devices and gastrointestinal bleeding: potential role of danazol. J Heart Lung Transplant 33:549–550CrossRefPubMedCentralGoogle Scholar
  25. 25.
    Juricek C, Imamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, Raikhelkar J, Ota T, Song T, Burkhoff D, Sayer G, Jeevanandam V, Uriel N (2018) Long-acting octreotide reduces the recurrence of gastrointestinal bleeding in patients with a continuous-flow left ventricular assist device. J Card Fail 24:249–254CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anthony P. Carnicelli
    • 1
    • 5
  • Anjali Thakkar
    • 1
    • 6
  • David J. Deicicchi
    • 1
    • 2
  • Andrew C. Storm
    • 1
    • 3
  • Jessica Rimsans
    • 1
    • 2
  • Jean M. Connors
    • 1
    • 4
  • Mandeep R. Mehra
    • 1
    • 2
  • John D. Groarke
    • 1
    • 2
  • Michael M. Givertz
    • 1
    • 2
    Email author
  1. 1.Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  2. 2.Cardiovascular Division, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  3. 3.Division of Gastroenterology and Hepatology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  4. 4.Division of Hematology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  5. 5.Division of Cardiology, Department of MedicineDuke University HospitalDurhamUSA
  6. 6.Department of MedicineUniversity of California San FranciscoSan FranciscoUSA

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