CONGRESS ABSTRACT

BACKGROUND: Gastrointestinal (GI) bleeding from intestinal angiodysplasia is a frequent complication of continuous-flow left ventricular assist device (CF-LVAD) support (≈25–30%). About 40% of patients develop recurrences, requiring rehospitalization and an elevated transfusion burden. Supraphysiologic shear stress and reduced pulsatility promote inflammatory/angiogenic mediators (TNF-α, VEGF), leading to maladaptive neovascularization and acquired von Willebrand factor dysfunction due to shear-related unfolding and ADAMTS13-mediated cleavage. After an appropriate diagnostic work-up, first-line management includes endoscopic investigations with direct hemostasis of bleeding lesions, reduction of antiplatelet therapy and INR targets, administration of vWF concentrates, and pharmacologic strategies such as octreotide, desmopressin, thalidomide (anti–TNF-α and anti-VEGF), and bevacizumab. In literature, ~270 angiodysplasia cases treated with thalidomide have been reported, including only 24 LVAD recipients (17 with >12-month follow-up). We report a refractory CF-LVAD case treated with thalidomide. CASE: A 67-year-old man with permanent atrial fibrillation and idiopathic thrombocytopenia, underwent Jarvik 2000 implantation in 2016 as bridge to transplant for non-ischemic dilated cardiomyopathy with pulmonary hypertension. From 2024 he developed admissions every 3-4 months for severe anemia. Repeated upper endoscopy and colonoscopy (including serial polypectomies) were frequently non-diagnostic as no definite bleeding source was identified; at the last admission both were negative, whereas capsule endoscopy showed small-bowel telangiectasias with intraluminal blood. Despite repeated endoscopic work-up, lowering of the INR target and octreotide, he continued to relapse and experienced complications related to frequent hospitalizations, including septic shock. Given the lack of further options, thalidomide was started at 50 mg/day and up-titrated to 100 mg/day without adverse effects. Given stable hemoglobin values (~10 g/dL), the patient was discharged home on August 2025; close follow-up (weekly, then every 2 weeks) showed a rise to 11.6 g/dL on December, with no need for dose reduction or discontinuation. CONCLUSION: Thalidomide may be an effective and apparently safe option for refractory angiodysplasia-related GI bleeding in CF-LVAD recipients with careful counseling and monitoring; however, its use remains off-label due to the lack of controlled studies.