Abstract WMP77: Neurovascular Complications During Long-term Left Ventricular Assist Device (LVAD) Support

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Abstract

Introduction: Left ventricular assist devices (LVAD) have emerged as the standard of care for treating patients with advanced heart failure refractory to maximal medical therapy. Postoperative cerebrovascular complications are an important cause of morbidity and decreased quality of life. However, the literature contains little data on the incidence, predictors, and outcome of stroke.

Hypothesis: We aimed to determine the incidence of cerebrovascular complications, their type, and association with stroke risk factors and anticoagulation therapy.

Methods: Data were collected prospectively on all patients with LVADs implanted at BWH. Categorical variables were tested by Chi-square.

Results: From 2007 to 2015, 151 patients (123 male; median age 57) underwent implantation of HeartMate II LVAD: 79 bridge to transplant, 62 destination therapy, and 10 bridge to candidacy.

Strokes occurred in 31 patients (21%). Risk of stroke did not correlate with sex (25 male, 6 female) or age (median at stroke onset 57). Seventeen acute ischemic strokes (AIS) occurred in 16 patients and 17 intracerebral hemorrhages (ICH) occurred in 15 patients. Four of the AIS were complicated by secondary hemorrhage. Events occurred at a mean of 362 days from implantation (range 5 days-6 years 8 months).

All patients except one were on warfarin at time of stroke (goal INR 2-3.5). Mean INR at AIS onset was 2.3 compared to 3.0 for ICH. Of the 15 ICH patients, 3 had supratherapeutic INR > 3.5. Eleven of the 16 AIS patients were also receiving ASA, 1 ASA + dipyridamole, 1 ASA + dipyridamole + bivalirudin. One received ASA only. All ICH patients and all those with AIS with secondary hemorrhage were on ASA.

Patients with COPD were more likely to have a stroke (p = 0.0006); 30 of the 151 patients had COPD and 13 of them (43%) had strokes. Risk of stroke did not correlate with DM, HTN, hyperlipidemia, CKD, PAD, AF, or prior stroke.

Nineteen of 31 patients with stroke versus 22 of 120 without stroke died (mortality 61 v 18 %; p << 0.001).

Conclusions: Stroke is an important cause of major morbidity and mortality in patients on LVAD support. Patients with COPD are at an increased risk of stroke. Further studies addressing post-LVAD stroke risk, prevention, and treatment are warranted.

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