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What Causes LVAD-Associated Ischemic Stroke? Surgery, Pump Thrombosis, Antithrombotics, and Infection

Cho, Sung-Min*,†; Hassett, Catherine; Rice, Cory J.; Starling, Randall; Katzan, Irene; Uchino, Ken

doi: 10.1097/MAT.0000000000000901
Original Article: PDF Only
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Acute ischemic stroke (AIS) is a major complication in left ventricular assist device (LVAD) population. A better understanding of clinical risk factors associated with AIS may help mitigate risk of stroke. We reviewed prospectively collected data of 477 LVAD patients from a tertiary center from October 1, 2004 to December 31, 2016. Supplemental data abstraction was performed on patients with AIS. Fifty-seven (12%) developed 61 AIS. Of 61, 17 (28%) AIS occurred perioperatively. The median time from implant to perioperative AIS was 5 days (interquartile range: 3–9). Pump thrombosis accounted for 19 (31%) of 61 AIS, and 7 (37%) presented initially with AIS before the pump thrombosis. The median lactate dehydrogenase (LDH) at the time of AIS in the pump thrombosis group (806) was higher than LDH at 1 month (437, P = 0.27) at 3 months (334, P = 0.01), and 6 months (286, P = 0.001) before AIS. Thirty-three (54%) AIS occurred while receiving inadequate antithrombotic therapy. Acute infections were common (31, 51%) in AIS and 12 (20%) were associated with acute bloodstream infection. All AIS were explained by a combination of four clinical risk factors. All LVAD-associated AIS occurred perioperatively or in conjunction with pump thrombosis, subtherapeutic anticoagulation, and bloodstream infection. The common underlying thread is occurrence of a prothrombotic state. The results of this study underscore the potential consequences of disruption of delicate hemostatic balance in patients with LVAD.

From the *Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, Ohio

Kaufman Center for Heart Failure and Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Submitted for consideration May 2018; accepted for publication in revised form August 2018.

Disclosure: S.M.C has nothing to disclose. C.H. has nothing to disclose. C.R. has nothing to disclose. R.C.S. has nothing to disclose. I.K. has nothing to disclose. K.U. serves on data safety monitoring board for device study by EVAHEART, Incorporated.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.asaiojournal.com)

S.M.C. and K.U. contributed to study concept and design. S.M.C., C.H., and C.R. contributed to data acquisition and analysis. S.M.C. and C.H. prepared the first draft of the manuscript. K.U., I.K., and R.C.S. contributed to drafting the manuscript. S.M.C. and K.U. finalized the manuscript.

Correspondence: Sung-Min Cho, Department of Anesthesiology, CCM Division of NCCU, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Phipps 455, Baltimore, MD 21287. Email: csmfisher@gmail.com.

Copyright © 2019 by the American Society for Artificial Internal Organs