Objectives We sought to evaluate predictors of stroke on LVAD from data available prior to implantation, and quantify stroke-related morbidity and mortality Background Stroke is a major complication after LVAD. Pre-implant factors that influence stroke are not well understood. Methods We evaluated all patients in the INTERMACS registry who were implanted with continuous-flow LVADs from May 1, 2012 to March 31, 2015. Preoperative risk factors for stroke, and stroke incidence, morbidity, and mortality were analyzed. Results During the study period, 7112 patients underwent CF LVAD placement. Median follow-up was 9.79 months (range 0.02–34.96 months). Of all patients, 752 (10.57%) had at least one stroke, with an incidence rate of 0.123 strokes per patient-year. 447 (51.38%) strokes were ischemic and 423 (48.62%) were hemorrhagic. Patients with hemorrhagic stroke had worse survival than those with ischemic strokes (30-day survival 45.3% vs. 80.7, p <0.001). Of patients with a first stroke, 13% had a second stroke. Pre-implant predictors of stroke were female gender (HR 1.51, 95% CI 1.25–1.82, p <0.001), pre-implant systolic blood pressure (HR 1.01, 95% CI 1.00–1.01, p = 0.002), heparin-induced thrombocytopenia (HIT) (HR 3.68, 95% CI 1.60–8.47, p = 0.002), intra-aortic balloon pump (IABP) (HR 1.21, 95% CI 1.01–1.46, p = 0.043), and primary cardiac diagnosis (ischemic/other/unknown) (p = 0.040). Conclusion Despite improvements in LVAD technology, stroke-related morbidity and mortality is substantial. Further investigation is necessary to decrease the risk of this devastating complication.

Background-Inotrope use in heart failure treatment was associated with improved symptoms, but worse survival in clinical trials. However, these studies predated use of modern heart failure therapies. This study evaluates contemporary outcomes on long-term inotropes. Methods and Results-We collected baseline and postinotrope data on 197 patients discharged on inotropes between January 2007 and March 2013. Baseline characteristics, hemodynamic and clinical changes on inotropes, and survival were evaluated. Patients initiated on inotropes had refractory heart failure, with median baseline New York Heart Association class IV, cardiac index of 1.7 L/min per m 2 , pulmonary capillary wedge pressure of 25.6 mm Hg, and left ventricular ejection fraction of 18.7%. Inotropes were used in patients listed for transplant or scheduled for left ventricular assist device (LVAD; 60 patients), in patients being evaluated for LVAD/transplant (20 patients), for stabilization pending cardiac resynchronization therapy/percutaneous coronary intervention (4 patients), in patients who were offered LVAD but chose inotropes (15 patients), and for palliation (98 patients). Milrinone was used in 84.8% and dobutamine in 15.2%. At the end of the study, 68 patients had died, 24 were weaned off inotropes, 23 were transplanted, 32 received LVADs, and 50 remained on inotropes. Patients who received inotropes for palliation or those who preferred inotropes over LVAD had median survival of 9.0 months (interquartile range, 3.1-37.1 months), actuarial 1-year survival of 47.6%, and 2-year survival of 38.4%. Of 60 patients who were placed on inotropes as a bridge to transplant/LVAD, 55 were successfully maintained on inotropes until transplant/LVAD. Conclusions-Survival on inotropes for patients who are not candidates for transplant/LVAD is modestly better than previously reported, but remains poor. Inotropes are effective as a bridge to transplant/LVAD. (Circ Heart Fail.

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