D0306 - Gastrointestinal Bleeding After Transcatheter Aortic Valve Replacement

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Ann F. Kopera, DO

MedStar Georgetown University Hospital
Washington, DC

Ann F. Kopera, DO¹, Mark Brahier, MD¹, Shwetha Kochi, BS¹, Jeffrey Riskin, BS¹, Kavya Sanghavi, MPH², Jose D. Vargas, MD¹, Monvadi B. Srichai, MD¹, Shervin Shafa, MD¹
¹MedStar Georgetown University Hospital, Washington, DC; ²MedStar Health Research Institute, Washington, DC

Introduction: Gastrointestinal bleeding (GIB) is the most common cause of late bleeding (>30 days) after transcatheter aortic valve replacement (TAVR). This finding is likely attributed to antithrombotic medications and underlying comorbidities. Data remains limited regarding risk factors for GIB and outcomes in long-term follow-up. This study sought to determine the incidence, risk factors, and outcomes of post-TAVR GIB up to one-year post-procedure.

Methods: A retrospective review was conducted which included 844 patients who underwent transfemoral TAVR between 2015-2020. The incidence of upper and lower GIB up to one-year follow up, demographics, medications, and baseline comorbidities were reviewed. The timing of the bleed was evaluated. Post-TAVR bleeds by one-year follow up were classified as minor, major, or life-threatening according to the VARC2 definitions. Severe anemia was defined as pre-operative hemoglobin less than 9. Triple therapy was defined as anticoagulation plus dual-antiplatelet therapy (DAPT). Bivariate and multivariable logistic regressions were used to determine independent predictors of GIB.

Results: Of the 844 patients included, the mean age was 79, and 55% were female sex. The incidence of GIB was 4.6% (n= 39). Regarding patients who experienced post-TAVR GIB, 10.3% (n=4) had a documented history of GIB (p=0.01). Baseline hemoglobin levels were lower in patients with GIB compared to no GIB [10.8 (9.4-12.4) vs. 12.1 (10.8-13.4) g/dL, p< 0.001]. Patients with CKD were more likely to have post-TAVR GIB compared to patients without CKD (41% vs. 24%, p=0.019). Post-TAVR GI bleeds were more likely to have occurred after discharge from TAVR hospitalization (82% vs. 41%, p< 0.0001) and were more often classified as major or life-threatening (62% vs 33%, p=0.0024) compared to patients with non-GI bleeds. Adjusting for all other covariates, the risk factors for GIB included triple therapy [OR 2.88 (95% CI: 1.04-7.97) p=0.042], and severe baseline anemia [HR 4.83 (95% CI: 2.15-10.84) p< 0.001].

Discussion: Triple therapy and severe baseline anemia are predictors of post-TAVR GIB by one-year post-procedure. Post-TAVR GIB is more likely to occur after TAVR hospitalization and more likely to be classified as a major or life-threatening bleed.

N (%) for binary variables Median (IQR) for continuous variables
	No GIB N=805	GIB N=39	p-value
Patient Demographics
Female sex	454 (56.4%)	15 (38.5%)	0.028
Age	79.6 (72.9-84.9)	78.3 (71.3-84.7)	0.37
BMI	28.5 (25.0-33.2)	28.7 (24.8-33.8)	0.798

Comorbidities
Baseline hemoglobin	12.1 (10.8-13.4)	10.8 (9.4-12.4)	< 0.001
Baseline MCV	91.9 (88.4-95.2)	90.4 (84.1-95.5)	0.425
Baseline creatinine	1.0 (0.81-1.3)	1.01 (0.78-1.5)	0.478
eGFR < 30	59 (7.5%)	3 (8.8%)	0.78
CKD	196 (24.3%)	16 (41.0%)	0.019
GI bleed history	23 (2.9%)	4 (10.3%)	0.01
Cirrhosis	9 (1.1%)	1 (2.6%)	0.415
Alcohol use disorder	16 (2.0%)	1 (2.6%)	0.802
Peptic ulcer disease	23 (2.9%)	2 (5.1%)	0.414
Diverticulosis	56 (7.0%)	4 (10.3%)	0.434
Esophageal varices	1 (0.1%)	1 (2.6%)	0.002
CAD	573 (71.2%)	30 (76.9%)	0.438
PAD	100 (12.4%)	9 (23.10%)	0.053
HTN	528 (65.6%)	29 (74.4%)	0.259
HLD	558 (69.3%)	30 (76.9%)	0.313
Diabetes	282 (35.0%)	18 (46.2%)	0.156

Medications Post-TAVR
DAPT	286 (35.5%)	13 (33.3%)	0.78
Anticoagulation	271 (33.9%)	13 (34.2%)	0.97
Triple therapy	44 (5.5%)	1 (2.6%)	0.431
PPI	241 (30.2%)	20 (52.6%)	0.003
H2 Antagonist	100 (12.5%)	8 (21.1%)	0.125

1 Year Outcomes
Any bleed	99 (12.3%)	39 (100%)	< 0.001
Major/Life-threatening bleeds	33 (33%)	24 (62%)	0.0024
Stroke	36 (4.5%)	4 (10.3%)	0.097
Myocardial infarct	22 (2.7%)	1 (2.6%)	0.95
Death	32 (4.0%)	4 (10.3%)	0.058

MCV: mean corpuscular volume; eGFR: estimated glomerular filtration rate; CKD: chronic kidney disease; CAD: coronary artery disease; PAD: peripheral artery disease; HTN: hypertension; HLD: hyperlipidemia; DAPT: dual-antiplatelet therapy; PPI: proton pump inhibitor.

Table: Table 1: Characteristics of post-TAVR GIB

Disclosures:

Ann Kopera indicated no relevant financial relationships.

Mark Brahier indicated no relevant financial relationships.

Shwetha Kochi indicated no relevant financial relationships.

Jeffrey Riskin indicated no relevant financial relationships.

Kavya Sanghavi indicated no relevant financial relationships.

Jose Vargas indicated no relevant financial relationships.

Monvadi Srichai indicated no relevant financial relationships.

Shervin Shafa: Pentax America – Consultant.

Ann F. Kopera, DO¹, Mark Brahier, MD¹, Shwetha Kochi, BS¹, Jeffrey Riskin, BS¹, Kavya Sanghavi, MPH², Jose D. Vargas, MD¹, Monvadi B. Srichai, MD¹, Shervin Shafa, MD¹. D0306 - Gastrointestinal Bleeding After Transcatheter Aortic Valve Replacement, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.