Are Blood Stream Infections Associated With an Increased Risk of Hemorrhagic Stroke in Patients With a Left Ventricular Assist Device?

Abstract

Blood stream infections (BSIs) are an important cause of morbidity and mortality in patients with left ventricular assist devices (LVADs). The aim of this study was to examine the correlation between hemorrhagic cerebrovascular accident (CVA) and BSI after implantation of LVAD for advanced heart failure (HF). This was a retrospective descriptive review of 87 patients with end-stage HF, who underwent implantation of HeartMate II continuous-flow LVAD over a 4 year period. Blood stream infections were diagnosed by serial blood cultures, and suspected neurological complications including CVAs were confirmed by neuroimaging. Extensive patient chart review was performed, and descriptive characteristics were analyzed using SPSS statistical software. The mean age of our study population was 62.3 ± 12.8 years, and the majority of our patients were males (n = 75, 86.2%). The baseline characteristics were comparable in the patients with and without CVAs. Patients with BSI had a much greater incidence of CVA compared to patients without BSI (n = 13, 43.3% vs. n = 5, 10.0%; p < 0.0001). There was an increased mortality in patients with BSI than those without (n = 57, 65.5% vs. n = 30, 34.5%; p = 0.003). The risk of all CVAs (hemorrhagic/ischemic) was eightfold (odds ratio [OR] = 7.9; 95% confidence interval [CI] = 2.4-25.5; p = 0.001] in patients with BSI. Patients with BSI had a >20-fold risk of hemorrhagic CVA (OR = 24; 95% CI = 2.8-201.1; p = 0.03). Advanced HF patients with LVAD support who developed BSI need urgent evaluation and close monitoring for suspected neurological complications, particularly hemorrhagic CVA.

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

“…The association that we found at our center between an increased risk of stroke and a history of sepsis has also been found in smaller previous studies as well, but it needs to be further examined. Infection or a proinflammatory state can contribute to systemic hypercoagulation, leading to potential thrombus formation and ischemic stroke [22]. A previous study has shown an asymmetry of stroke distribution, with rightsided strokes being more prevalent in LVAD patients, especially in patients with infections.…”

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.…”

Persistent Blood Stream Infection in Patients Supported With a Continuous-Flow Left Ventricular Assist Device Is Associated With an Increased Risk of Cerebrovascular Accidents

“…13,14 Most of these studies included patients with both continuous-flow LVADs (CF-LVADs) and pulsatile-flow devices, thus limiting the extrapolation of these studies to contemporary LVAD usage, because CF-LVADs comprise O95% of current implantations. Patients with CF-LVADs have lower rates of both infection and CVA compared with patients who receive pulsatileflow LVADs.…”

“…A recent pilot study found an association between CVA and any BSI in patients supported with Heartmate II (HMII; Thoratec Corp, Pleasanton, California) LVADs. 13 We conducted a retrospective study to explore these observations further with the specific aim to determine if persistent BSI (as opposed to transient BSI) is associated with an increased risk of all-cause CVA (hemorrhagic and/or ischemic) and all-cause mortality in patients who underwent HMII implantation at our institution.…”