Z. M. Bauman1, R. Cunningham1, A. Hodson1, V. Shostrom1, C. Evans1, L. Schlitzkus1 1University Of Nebraska College Of Medicine,Acute Care Surgery,Omaha, NE, USA
Introduction: The LVAD patient population is rapidly expanding. Few institutions have experience managing these patients. The unique characteristics of this patient population complicate the management of acute surgical problems due to lack of knowledge concerning LVADs and the necessary anticoagulation for this device. EGS intervention is often warranted, but remains poorly described. We reviewed our EGS cases in LVAD patients to understand this patient population and approach to treatment.
Methods: Over a 12-year period, 301 LVAD patients were reviewed. Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation and mortality were noted. Continuous variables were analyzed using the nonparametric Wilcoxon test and categorical variables were analyzed using the Fischer Exact and Chi-Square test. Statistical significance was set at p<0.05.
Results: A total of 139 (46.2%) patients required EGS consultation. Patients with EGS consults were older (63 vs 57 years, p=0.002), primarily Caucasian (86%) males (83%) with an average pre-implant cardiac index (CI) of 1.84. Comorbidities were similar between those with and without EGS consults.
Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%). Unfortunately those requiring EGS consults were taking warfarin (77%) and aspirin (60%). Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy.
Surgical intervention was undertaken in 28% of those with an EGS consults – 49% emergent (within 24 hours), 44% urgent (during hospitalization) and 8% semi-urgent. The mean time to operation was 48 days post-LVAD placement (interquartile range of 11-273 days). EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) suffered perioperative mortality. Only elevated lactic acid at the time of EGS consult was associated with an increased likelihood of mortality.
Conclusion: EGS consultation is necessary in almost half of all LVAD patients. Most commonly, GI bleeding is the main reason worsened by the anticoagulation required for the LVAD device. Although EGD or colonoscopy can be safely used to manage the majority of these consultations, one third will require surgical intervention. At consultation, those patients with a high lactic acid have a higher incident of mortality. Additional analysis of this patient population is required for further assessment to determine the timeliness of the consult, for better preoperative optimization and risk benefit discussion.
