Stroke after implantation of continuous flow left ventricular assist devices

Abstract

Objective Stroke remains a frequent and devastating complication after left ventricular assist device (LVAD) implantation, despite recent advances in device technology. The aim of this study was to analyze risk factors and outcomes of stroke following implantation of 200 continuous‐flow LVADs at our institution. Methods We retrospectively analyzed patients who underwent LVAD implantation from 2011‐2016. Data were available for a total of 200 patients. Results Post‐LVAD stroke occurred in 13% of patients (26 of 200). Ischemic stroke occurred in 50% of patients (13 of 26), and hemorrhagic stroke in 50% (13 of 26). The median duration of LVAD support at the time of stroke was 257.4 days. Baseline characteristics did not differ significantly between the stroke and stroke‐free cohorts. The mean international normalized ratio (INR) at the time of embolic stroke was 1.86 (range, 1.23‐3.25) and 4.62 (range, 1.4‐21.4) in patients with hemorrhagic stroke (P = .014). Mortality within 30 days of stroke was 31% (8 of 26). Mortality for hemorrhagic stroke was 63% (5 of 8) and 37% (3 of 8) for ischemic stroke ( P = .03). Among the 18 patients that survived stroke, 28% (5 of 18) received a heart transplant, 39% (7 of 18) are receiving ongoing LVAD support, and 33% (6 of 18) have died from unrelated causes. Multivariate analysis showed that INR level, aortic cross‐clamping, a history of previous stroke, and postoperative infection were significant predictors for post‐LVAD stroke. Conclusion The occurrence of stroke significantly increases morbidity and mortality after LVAD implantation. Despite an adverse impact on survival and quality of life, several patients who suffered stroke still received a heart transplant. Furthermore, none of our patients had recurrence of a neurological event. Strict implementation of anticoagulation protocols is likely the mainstay of preventing this devastating complication.

Bridge from central extracorporeal life support is a risk factor of cerebrovascular accidents after durable left ventricular assist device implantation

“…Survival outcome was not significantly different between the two groups. The postoperative survival rate and cumulative incidence of CVAs in this cohort are comparable with the outcomes of previous studies [ 13 – 17 ]. Notably, this bridge strategy was the only independent predictive factor of CVAs post-implantation of HeartMate II or HeartMate 3.…”

Pharmacotherapy for durable left ventricular assist devices

“…Ischemic and hemorrhagic strokes are potentially devastating complications of LVAD therapy, with hemorrhagic strokes portending worse morbidity and mortality 66,88,89 . Risk factors for stroke include active infection, 90–93 sub‐ or supratherapeutic anticoagulation, 66,89,90,93,94 female sex, 71,88 increased blood pressure, 66,88,89,91,95 renal dysfunction, 96 tobacco use, 91 peripheral vascular disease, 89 chronic obstructive pulmonary disease 96 and diabetes 71,94 …”

Stroke in Patients with Left Ventricular Assist Devices

“…Although the bulk of clinical trial data suggest a preponderance toward ischemic stroke (Table 1), prospective registry data report ischemic and hemorrhagic stroke in equal proportions [15]. Previous research has identified a bimodal distribution of stroke risk, with a peak around the time of surgical insertion, and a second peak around 1 year post-implantation [16-19]. However, the stroke rate varies depending on device generation, with lower rates of stroke seen with further refinement of device technology [20].…”