Endoscopic treatment of severe episodic epistaxis in a patient with a left-ventricular assist device

摘要

Epistaxis is a common otolaryngologic emergency that prompts medical or surgical intervention in up to 6% of the population. Presence of LVADs is a unique risk factor and non-surgical bleeding has been reported as the most common adverse event of CF-LVAD support. Given their anticoagulation requirements and complex medical profiles, these patients represent a challenging cohort for otolaryngologists managing their epistaxis.We present the case of a 63-year-old Asian female with non-ischemic cardiomyopathy, congestive heart failure who underwent an uncomplicated CF-LVAD placement. Three weeks after the procedure, the patient developed recurrent epistaxis requiring nasal and oropharyngeal packing. She remained intermittently hemostatic for two days before another episode of severe epistaxis prompted return to the OR. Nasal endoscopy revealed diffuse telangiectatic mucosal lesions consistent with endonasal AVMs. Bilateral sphenopalatine artery ligations and ablation of the AVMs with KTP lasers was performed. Patient remained hemostatic after the procedure and underwent successful cardiac transplant two months later.Patients with CF-LVADs represent a growing population with unique risk factors for recalcitrant and severe epistaxis. Underlying systemic coagulopathies and diffuse distribution of AVMs throughout bilateral nasal cavities can limit effective bedside management. Prompt operative intervention with nasal endoscopy should be considered in this growing patient population.