Risk factors for stroke on left ventricular assist devices

Abstract

Postoperative stroke after LVAD implantation was associated with higher mortality. A history of previous CVA, VTE, and hyperlipidemia were independently associated with stroke while on LVAD support.

Strokes associated with left ventricular assist devices

“…The most serious and persistent problem with ventricular assist devices (VADs) is stroke, which has remained relatively constant at a rate of 10‐20% at 2 years . The high complication rates of pulsatile‐flow VADs resulted in the development of electromechanical continuous‐flow (non‐pulsatile) pumps that employ either a centrifugal or axial pump configuration that use electromagnets to spin the central rotors .…”

“…Other observational studies in recent years have yielded mixed overall results as well . Most recently, Bishawi et al showed a significant decrease in cerebrovascular accidents (CVAs) with centrifugal pumps (23% vs 77%) . Therefore, while the ENDURANCE and Supplemental ENDURANCE trials, Cho's extensive analysis, and numerous other observational reports have added significantly to the understanding of these two LVAD devices, it is difficult to state definitively that one of them is superior to the other in terms of causing debilitating neurologic catastrophes.…”

“…The risk factors for stroke in VAD patients are multi‐factorial and include high MAP, infection, device thrombosis, gastrointestinal bleeding, and anti‐thrombotic treatment that is either too high or too low. Recently, Bishawi et al also noted that a history of prior CVA, hyperlipidemia, and venous thromboembolism was associated with an increased risk of CVA on LVADs . Cho's comprehensive review of the literature revealed that both ischemic and hemorrhagic strokes occur more often in LVAD recipients than in non‐LVAD patients who are on similar anticoagulant regimens, suggesting that the LVADs themselves increase the risk of stroke .…”

Strokes are the achilles heel of LVAD therapy

“…Last month, Bishawi et al reported the outcomes of stroke in LVAD patients at the Duke University Medical Center . In 390 LVAD patients, 61 patients (15.6%) sustained a stroke while on LVAD therapy.…”

“…Mechanical thrombectomy has been shown to improve outcomes in patients with strokes on LVAD support and all patients who have suffered an acute stroke should be evaluated for this therapy . Finally, as noted by Bishawi et al, patients who have had a previous stroke or have had or are prone to venous thromboemboli should be carefully screened when selecting candidates for LVAD therapy because of their increased risks for cerebrovascular events. Better patient selection, more aggressive blood pressure control, and anticoagulation control and continued improvements in LVAD technology will be necessary to decrease the incidence of this catastrophic complication.…”