Stroke After Left Ventricular Assist Device Implantation: Outcomes in the Continuous-Flow Era

Harvey, Laura; Holley, Christopher L.; Roy, Samit S.; Eckman, Peter; Cogswell, Rebecca; Liao, Kenneth; John, Ranjit

doi:10.1016/j.athoracsur.2015.02.094

Cited by 107 publications

(78 citation statements)

References 26 publications

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“…6 Our study found that the risk of in-hospital mortality after stroke did not vary with stroke subtype, which is consistent with a recent single-center study of outcome after stroke in the LVAD population. 7 However, in contrast to the twofold risk of mortality after stroke seen in their cohort, we found a six-fold risk of in-hospital mortality. 7 The discrepancy may be because we considered only in-hospital mortality, the rate of which may be greater in stroke patients.…”

Section: Discussioncontrasting

confidence: 90%

“…7 However, in contrast to the twofold risk of mortality after stroke seen in their cohort, we found a six-fold risk of in-hospital mortality. 7 The discrepancy may be because we considered only in-hospital mortality, the rate of which may be greater in stroke patients. Our finding of an elevated risk of in-hospital mortality after stroke in VAD patients is also consistent with findings of registry data 2 and a large study demonstrating reduced survival in patients with LVAD-related thromboembolic events.…”

Section: Discussioncontrasting

confidence: 90%

“…2, 5 It is customary to maintain VAD patients on therapeutic anti-coagulation with warfarin and an anti-platelet agent, typically aspirin. 1, 6, 7 Estimates of stroke risk in patients with VADs vary widely, 8–11 but registry data show a cumulative overall stroke rate of 19% by 3 years. 4 Risk factors and the characteristics and outcomes of stroke in patients with VADs have not been well defined.…”

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confidence: 99%

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Stroke Risk and Mortality in Patients With Ventricular Assist Devices

Parikh

Cool

Karas

et al. 2016

Stroke

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Background and Purpose Ventricular assist devices (VADs) have advanced the management of end-stage heart failure. However, these devices are associated with hemorrhagic and thrombotic complications, including stroke. We assessed the incidence, risk factors, and outcomes of ischemic and hemorrhagic stroke after VAD placement. Methods Using administrative claims data from acute care hospitals in California, Florida, and New York from 2005–2013, we identified patients who underwent VAD placement, defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 37.66. Ischemic and hemorrhagic strokes were identified by previously validated coding algorithms. We used survival statistics to determine incidence rates and Cox proportional hazard analyses to examine associations. Results Among 1,813 patients, we identified 201 ischemic strokes and 116 hemorrhagic strokes during 3.4 (±2.0) years of follow-up after implantation of a VAD. The incidence of stroke was 8.7% per year (95% confidence interval [CI], 7.7–9.7%). The annual incidence of ischemic stroke (5.5%; 95% CI, 4.8–6.4%) was nearly double that of hemorrhagic stroke (3.1%; 95% CI, 2.6–3.8%). Women faced a higher hazard of stroke than men (hazard ratio [HR], 1.6; 95% CI, 1.2–2.1), particularly hemorrhagic stroke (HR, 2.2; 95% CI, 1.4–3.4). Stroke was strongly associated with subsequent in-hospital mortality (HR, 6.1; 95% CI, 4.6–7.9). Conclusions The incidence of stroke after VAD implantation was 8.7% per year, and incident stroke was strongly associated with subsequent in-hospital mortality. Notably, ischemic stroke occurred at nearly twice the rate of hemorrhagic stroke. Women appeared to face a higher risk for hemorrhagic stroke than men.

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Section: Discussioncontrasting

confidence: 90%

Section: Discussioncontrasting

confidence: 90%

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Stroke Risk and Mortality in Patients With Ventricular Assist Devices

Parikh

Cool

Karas

et al. 2016

Stroke

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“…Studies have reported both sub-therapeutic (13,20) and supra-therapeutic INR (15) levels as risk factors, and many studies including ours have failed to find any relationship between coagulation status and IS and ICH rates (25,26). The pathogenesis of ICH and IS in LVAD patients is multifactorial, and coagulation status is likely to be just one factor among a multitude of reasons why LVAD patients experience stroke.…”

Section: Discussionmentioning

confidence: 99%

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device

et al. 2018

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Background: Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients.Methods: All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results:Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance.Conclusions: Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4-and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS. Shahreyar et al. CVA in patients with LVAD

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“…Although these devices provide a critical bridgeto-transplant along with destination therapy, ischemic stroke remains a devastating and unfortunate risk associated with these devices.Prior series have reported incidence of ischemic stroke as high as 17%, at times occurring in the perioperative period [1][2][3].…”

Section: Introductionmentioning

confidence: 99%

First Reported Case of Mechanical Thrombectomy for Acute Ischemic Stroke in an Individual with a Total Artificial Heart

Eboli¹

2016

JNSK

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Background: With the results of recent thrombectomy trials, endovascular therapy (EVT) is standard of care in appropriately selected patients with acute ischemic stroke (AIS). We report the first case of mechanical thrombectomy for a patient supported by a total artificial heart (TAH) with AIS.Clinical presentation: A 37 year old male patient with ischemic cardiomyopathy was found to have right gaze preference, left facial droop, and global aphasia 9 days following implantation of a TAH. Prior to ictus, antithrombotic regimen included daily aspirin and heparin infusion at therapeutic levels. Acute imaging revealed a 6 mm left M2 thrombus with associated perfusion mismatch seen in the left MCA territory along with a smaller matched perfusion defect seen in the right MCA territory.Intervention: Following confirmation of lesion amenable to mechanical thrombectomy, patient underwent successful TICI 3 revascularization of the left MCA territory with a Solitaire stent retriever. Repeat perfusion imaging revealed resolved left MCA territory mismatch with persistent right MCA matched defect. His speech improved to an expressive aphasia following revascularization. Conclusion:EVT has been proven to be safe and efficacious for AIS. Prior reports have demonstrated benefit for patients with concurrent mechanical circulatory support devices; however, our report is the first case demonstrating efficacy with a TAH device. Presence of mechanical circulatory support devices should not exclude EVT in individuals with AIS. BackgroundMechanical circulatory support provides an important therapeutic intervention for those with critically depressed cardiac function. Although these devices provide a critical bridgeto-transplant along with destination therapy, ischemic stroke remains a devastating and unfortunate risk associated with these devices.Prior series have reported incidence of ischemic stroke as high as 17%, at times occurring in the perioperative period [1-3].Current management strategies aimed at preventing ischemic strokes focus on systemic anticoagulation. When an ischemic stroke does occur, these individuals are usually not candidates for intravenous thrombolytic therapy due to these factors, allowing a potential reversible ischemic event to progress to tissue infraction. Fortunately, mechanical thrombectomy does remain a viable treatment option, in select patients [4][5][6][7][8]. Prior reports have reported individual cases of successful mechanical thrombectomy in individuals with left ventricular devices, but no such intervention has been reported with concurrent total artificial heart implantation [9,10]. We report the first such case of successful mechanical thrombectomy for acute ischemic stroke in an individual with a total artificial heart. CaseA 39 year old gentleman with history of ischemic cardiomyopathy was transferred to our tertiary care academic medical center following presentation at an outside hospital for worsening dyspnea and chest pain. He was found to have severe 3 vessel cardiac disease and ...

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Stroke After Left Ventricular Assist Device Implantation: Outcomes in the Continuous-Flow Era

Cited by 107 publications

References 26 publications

Stroke Risk and Mortality in Patients With Ventricular Assist Devices

Stroke Risk and Mortality in Patients With Ventricular Assist Devices

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device

First Reported Case of Mechanical Thrombectomy for Acute Ischemic Stroke in an Individual with a Total Artificial Heart

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