Intracranial Hemorrhage in Patients with Durable Mechanical Circulatory Support Devices: Institutional Review and Proposed Treatment Algorithm

A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device–Associated Stroke

“…Nonphysiological continuous blood flow and decreased pulsatility by pump device can induce shear stress on the endothelium and blood components, leading to acquired von Willebrand's disease, 94,95 seen in 58 to 100% of LVAD patients with bleeding complications. 85,[96][97][98] A recent multicenter prospective comparative analysis study of 60 patients demonstrated that HeartMate 3 was associated with greater preservation of the structure of von Willebrand factor high-molecular-weight multimers than the HeartMate II, which may have resulted in lower stroke rates in Heart-Mate 3. 99 Furthermore, continuous blood flow may result in loss of autoregulation that, in turn, increases the risk of cerebrovascular events such as ICH, 93 but a causal relationship is yet to be confirmed.…”

“…24 However, a clear association between ICH and INR level has not been established. [83][84][85] One large study reported a mean INR of 1.8 at the time of ICH, 9 and a systematic review found median INR at the lower end of therapeutic range (2.1) at the time of stroke. 15 In a recent systematic review of ICH in LVAD patients, mean INR across included studies was 2.7 (range: 1.3-3.8).…”

“…The most common type is intraparenchymal hemorrhage, seen in 40 to 60% and associated with worse outcomes, followed by subarachnoid hemorrhage, subdural and epidural hematomas. 9,24,54,81,[83][84][85][86][87] Patients may experience more than one type of ICH, and hemorrhages are typically more extensive and more likely to be lobar, 16 attributable to chronic anticoagulation in this population. Also, most hemorrhages occur spontaneously and with worse outcomes than traumatic ICH.…”

“…Prolonged anticoagulation required to prevent thromboembolic events, particularly with increased duration of LVAD support as destination therapy, increases the risk of hemorrhagic complications. A higher rate of cerebrovascular disease in LVAD patients compared with those on chronic anticoagulation without LVAD 85,[88][89][90][91][92] raises the suspicion for other involved mechanisms 93 (►Fig. 1).…”

Anticoagulant treatment and bleeding complications in patients with left ventricular assist devices

“…Secondary ICH was observed in 27% of the patients during one year follow-up, after a median time of 229 days post-anticoagulant resumption. A stepwise approach for managing ICH in LVAD patients has previously been proposed, only performing active anticoagulant reversal in case of large ICH (defined as intraparenchymal hemorrhage >3 cm or subarachnoid hemorrhage >1-2 mm thickness), with no specific guidance for duration of anticoagulation [91]. Such a strategy has however not been validated by an outcome study.…”