Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device

Abstract

BACKGROUND Neurologic complications (NCs) are the major adverse events after left ventricular assist device (LVAD) surgery. Pre-operative and post-operative factors associated with NCs in patients with LVADs were investigated. METHODS We reviewed 307 consecutive patients undergoing LVAD surgery (167 HeartMate I and 140 HeartMate II devices) at Columbia University Medical Center between November 2000 and December 2010. Clinical characteristics and hemodynamic and laboratory indexes were analyzed. NC was defined according to the Interagency Registry for Mechanically Assisted Circulatory Support definition of neurologic dysfunction, including transient ischemic attack (TIA) and ischemic or hemorrhagic cerebrovascular accident (CVA). RESULTS NCs developed in 43 patients (14.0%) at 91.8 ± 116.3 days post-operatively. The frequency of NC development was similar in HeartMate I and II patients. Patients with NC showed a higher frequency of pre-LVAD CVA history (27.9% vs 15.5%, p = 0.046), lower pre-operative sodium (129.0 ± 7.0 vs 132.1 ± 8.1 mg/dl, p = 0.018) and albumin concentrations (3.5 ± 0.7 vs 3.7 ± 0.6 mg/dl, p = 0.049), lower post-operative hematocrit (34.9% ± 5.1% vs 37.8% ± 6.1%, p = 0.0034), sodium (131.6 ± 7.7 vs 134.4 ± 6.4 mg/dl, p = 0.010) and albumin concentrations (3.7 ± 0.5 vs 3.9 ± 0.5 mg/dl, p = 0.0016), and higher frequency of post-operative infection (39.5% vs 19.3%, p = 0.003) than those without NC. Multiple regression analysis revealed that CVA history (odds ratio, 2.37, 95% confidence interval, 1.24 –5.29; p = 0.011) and post-operative infection (odds ratio, 2.99, 95% confidence interval, 1.16 –10.49; p = 0.011) were highly associated with NC development. The combination of CVA history, pre-operative and post-operative sodium and albumin, and post-operative hematocrit and infection could discriminate patients developing NCs with a probability of 76.6%. CONCLUSIONS Previous stroke, persistent malnutrition and inflammation, severity of heart failure, and post-LVAD infections are key factors associated with development of NCs after LVAD implantation.

Asymmetric Pattern of Cerebrovascular Lesions in Patients After Left Ventricular Assist Device Implantation

“…We reported recently that patients with postoperative infection are more prone to develop stroke than those without infection after LVAD implantation. 9 Infection precipitates coagulation abnormalities that may lead to a high frequency of LVADrelated thrombus formation resulting in right hemispheric stroke. Limitation of this study is that it is a single-center, retrospective analysis in a small cohort of patients.…”

“…Anticoagulation protocol included heparin, warfarin, and antiplatelet agents, such as aspirin and/or dipyridamole, except for those patients with contraindication to the medication or/and active bleeding. 9 Clinical characteristics, postoperative infection frequency, and anticoagulant status associated with right and left hemispheric stroke were compared. We excluded bilateral and vertebrobasilar stroke from the comparison analysis.…”

A Review of Infections in Patients with Left Ventricular Assist Devices: Prevention, Diagnosis and Management

“…In addition, the greater the amount of time supported by a CF-LVAD, the greater the risk of developing a PSI. 6 Several studies have reported an association between infection and cerebrovascular events (CVEs) in patients supported with LVADs, [7][8] and we recently reported that persistence of bacteremia greater than 72 hours is a crucial distinguishing factor. 9 We recently reported a 7-fold increase in CVEs in patients with HeartMate-II (HMII) devices who have persistent Pseudomonas aeruginosa bloodstream infections.…”

Physiological Impact of Continuous Flow on End-Organ Function: Clinical Implications in the Current Era of Left Ventricular Assist Devices

“…32 Infection leading to bacteremia and septic emboli are added mechanisms specific to VAD patients due to their high prevalence of chronic infections. 33 Bacteremia is associated with a > 8-fold increase in risk of stroke. 34 Inflammatory activation and lack of pulsatility impacting endothelial function in the cerebral circulation could have a significant role but has not been studied.…”