Introduction: Left ventricular assist device (LVAD) is used for the management of advanced heart failure patients and associated with a significant risk of gastrointestinal (GI) bleeding. We describe a case of LVAD related recurrent GI bleeding unresponsive to conventional management and successfully treated with a combination of subcutaneous and intramuscular depot formulations of octreotide.

Case report: Patient is a 61-year-old man with ischemic cardiomyopathy who was implanted with a HeartMate II LVAD as a bridge to transplantation. The initial anticoagulation regimen consisted of a vitamin K antagonist (warfarin) with a goal international normalized ratio (INR) of 2-3, aspirin of 150 mg daily and clopidogrel of 75 mg added after percutaneous coronary intervention of native coronary vessel. Three weeks following discharge, the patient was evaluated for melena, necessitating blood transfusions. Over next four months he had repeated hospital readmissions, each requiring multiple blood transfusions despite stopping the aspirin, clopidogrel and reducing the goal INR to 1.5–2.0. No evidence of Von Willebrand syndrome, hemolysis or pump malfunction was revealed. Repeated esophagogastroduodenoscopy and colonoscopy did not reveal any active source of bleeding. Red blood cell scintigraphy bleeding scan and capsule endoscopy revealed on one occasion bleeding in the proximal small bowel, but no identifiable source. LVAD pump speed was also reduced in an effort to achieve increased pulsatility. He was started on 100 μg SC octreotide twice daily and then switched to 10 mg IM injections monthly. Due to recurrent bleeding warfarin was discontinued for period of 20 days without sign of pump thrombosis, and anticoagulation was continued applying low molecular heparin. He did not require any transfusions for 3 months, and his hemoglobin remains stable.

Discussion: Gastrointestinal bleeding is the most common cause of readmission in patients supported by continuous flow left ventricular assist devices, mainly continuous flow LVADs. (1, 2) Octreotide exhibit a favorable trend in the frequency of admissions, blood transfusions in patients with recurrent GI bleeding but further prospective studies are needed.