Stroke in Patients with Left Ventricular Assist Devices

Abstract

<b><i>Background:</i></b> Left ventricular assist devices (LVADs) are artificial pumps used in end-stage heart failure to support the circulatory system. These cardiac assist devices work in parallel to the heart, diverting blood from the left ventricle through an outflow graft and into the ascending aorta. LVADs have allowed patients with end-stage heart failure to live longer and with improved quality of life compared to best medical therapy alone. However, they are associated with significant risks related to both thrombosis and bleeding in this medically complex patient population. As LVADs continue to be used more widely, stroke neurologists need to become familiar with the unique physical exam and vascular imaging findings associated with this population. <b><i>Summary:</i></b> Reported rates of LVAD-associated stroke at 2 years post-implantation range from 10 to 30%, which is significantly higher than in age-matched controls. There are approximately equal rates of ischemic and hemorrhagic strokes, and rates are highest during the peri-implantation period and in the first year of therapy. Risk factors associated with ischemic and hemorrhagic stroke in this cohort can be grouped into treatment-related factors, including specific devices and antithrombotic/anticoagulation strategy, and patient-related factors. Evidence for reperfusion therapy for acute stroke in this population is limited. Intravenous tissue plasminogen activator (IV-tPA) is often contraindicated as events may occur in the perioperative setting, or in the context of therapeutic anticoagulation. Endovascular therapy with successful recanalization is reported, but there is little experience documented in the published literature. <b><i>Key messages:</i></b> LVAD use is increasingly common. Given the high associated risks of stroke, neurologists will need to become increasingly familiar with an approach to assessment and therapy for LVAD patients with cerebrovascular issues.

Interplay between driveline infection, vessel wall inflammation, cerebrovascular events and mortality in patients with left ventricular assist device

“…It is striking that 64% of patients were hospitalised at the time of stroke due to bleeding, pump thrombosis, hypertension and atrial fibrillation presenting pre-described risk factors for ischemic strokes 6 , 39 . Consecutive adjustments in anticoagulation and concomitant conditions additionally pose according competing risks for stroke 45 .…”

Left ventricular assist device implantation combined with hemiarch replacement for severe aortic atherosclerosis

“…The effects of LVAD flow on aortic wall have been investigated. Shear stress due to ventricular assist device flow is reported to cause endothelial damage and atherosclerotic change in native vessels ( 1 ). Significantly increased medial degeneration and atherosclerotic changes after LVAD support have also been reported ( 7 ).…”

“…Left ventricular assist device (LVAD) implantation has been a widely used treatment for selected patients with advanced heart failure. Rates of LVAD-associated stroke are reported to range from 10% to 30% depending on the follow-up period ( 1 , 2 ).…”

Assessing the Safety and Feasibility of Portable Low-Field Magnetic Resonance Imaging With HeartMate 3 Left Ventricular Assist Device

“…Stroke is a leading cause of mortality in patients supported by left ventricular assist devices (LVAD) and a contraindication for cardiac transplantation in several centers. [1][2][3] Early detection of stroke is crucial in the management of these patients, which may potentially improve their clinical outcomes. Portable low-field brain magnetic resonance imaging (pMRI) has been shown to be safe for extracorporeal membrane oxygenation (ECMO) patients, even with an intra-aortic balloon pump (IABP) or Swan Ganz catheter (SGC); however, its safety in LVAD patients is untested.…”