My elderly patient with aortic stenosis has iron deficiency in the setting of Heyde’s syndrome. Can surgical or transcatheter aortic valve replacement (SAVR, TAVR) reduce her risk of future gastrointestinal bleeding?

Yes! Heyde’s syndrome, characterized by aortic stenosis and GI angiodysplasia1, appears to respond to SAVR or TAVR by reducing future risk of GI bleed.

Cessation of bleeding following SAVR or TAVR with gradual disappearance of angiodysplasia has been reported, in some cases despite long-term anticoagulant therapy2,3In fact, GI bleed may cease in 95% of cases following AVR vs 5% in cases controlled with laparotomy with or without bowel resection.  Further supporting the potential role of valve replacement is the observation that in patients who have undergone SAVR, aortic valve restenosis usually leads to the recurrence of GI bleeding which again resolves after redo surgery.

The pathophysiology of Heyde’s syndrome involves not only increased number of angiodysplasias but higher risk of bleeding from them.  Although its exact  physiological link is unclear, hypo-oxygenation of intestinal mucosa—possibly related to cholesterol emboli with resultant vasodilatation—has been hypothesized, among many others.4   Bleeding from angiodysplasias appears related to the high shear stress across the stenotic aortic valve, leading to acquired von Willebrand’s disease (Type 2AvWF disease) and coagulopathy.4

 

References

    1. Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med 1958;259:196. https://www.nejm.org/doi/full/10.1056/NEJM200209123471122
    2. Abi-akar R, El-rassi I, Karam N et al. Treatment of Heyde’s syndrome by aortic valve replacement. Curr Cardiol Rev 2011;  7:47–49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131716/
    3. Pyxaras, SA, Santangelo S. Perkan A et al. Reversal of angiodysplasia-derived anemia after transcatheter aortic valve implantation. J Cardiol Cases 2012; 5: e128–e131. https://www.sciencedirect.com/science/article/pii/S187854091100079X
    4. Kapila A, Chhabra L, Khanna A. Valvular aortic stenosis causing angiodysplasia and acquired von Willebrand’s disease: Heyde’s syndrome. BMJ Case Rep 2014 doi:10.1136/bcr-2013-201890. http://casereports.bmj.com/content/2014/bcr-2013-201890.full.pdf

 

Contributed by Biqi Zhang, Medical Student,  Harvard Medical School

If you liked this pearl, sign up under menu and receive future pearls straight into your mailbox!

My elderly patient with aortic stenosis has iron deficiency in the setting of Heyde’s syndrome. Can surgical or transcatheter aortic valve replacement (SAVR, TAVR) reduce her risk of future gastrointestinal bleeding?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s