Neuroendovascular Interventions for Acute Ischemic Strokes in Patients Supported with Left Ventricular Assist Devices: A Single-Center Case Series and Review of the Literature

Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review

There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

Stroke and Mechanical Circulatory Support in Adults

PURPOSE OF THE REVIEW

Short-term and durable mechanical circulatory support (MCS) devices represent life-saving interventions for patients with cardiogenic shock and end-stage heart failure. This review will cover the epidemiology, risk factors, and treatment of stroke in this patient population.

RECENT FINDINGS

Short-term devices such as intra-aortic balloon pump, Impella, TandemHeart, and Venoatrial Extracorporal Membrane Oxygenation, as well as durable continuous-flow left ventricular assist devices (LVADs), improve cardiac output and blood flow to the vital organs. However, MCS use is associated with high rates of complications, including ischemic and hemorrhagic strokes which carry a high risk for death and disability. Improvements in MCS technology have reduced but not eliminated the risk of stroke. Mitigation strategies focus on careful management of anti-thrombotic therapies. While data on therapeutic options for stroke are limited, several case series reported favorable outcomes with thrombectomy for ischemic stroke patients with large vessel occlusions, as well as with reversal of anticoagulation for those with hemorrhagic stroke. Stroke in patients treated with MCS is associated with high morbidity and mortality. Preventive strategies are targeted based on the specific form of MCS. Improvements in the design of the newest generation device have reduced the risk of ischemic stroke, though hemorrhagic stroke remains a serious complication.

Catheter thrombectomy for basilar artery stroke immediately after insertion of durable left ventricular assist device

Background: Acute ischemic stroke (AIS) following left ventricular assist device (LVAD) implantation is a serious complication associated with device morbidity. AIS development following LVAD placement typically presents between 6- and 24-months post implantation.Case/Results: We report a case of a 67-year-old male who initially presented with reduced ejection fraction and severe coronary vessel disease. Following coronary artery bypass graft surgery, the patient remained in a low output state necessitating placement of an LVAD device. Approximately 4.5 hours following LVAD implantation, a severe acute decrease in mental status revealed new development of ischemic stroke of the basilar artery, which was successfully treated in one pass with catheter endovascular thrombectomy.Conclusion: While embolic stroke management in these cases remains difficult as patients are usually anticoagulated, our case demonstrates the utilization of endovascular thrombectomy as a viable therapeutic option in the setting of an uncommon occurrence of embolic stroke in the hours following LVAD implantation.

Mechanical thrombectomy after acute ischemic stroke in patients with left ventricular assist devices: A nationwide analysis

INTRODUCTION

Left ventricular assist devices (LVADs) are an established, durable, and life-saving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population, but LVO trials largely excluded patients on mechanical circulatory support, and large-scale analyses of outcomes following these interventions in the LVAD population are lacking.

METHODS

Using the National Inpatient Sample, we identified all adult patients hospitalized with acute ischemic stroke (AIS) from 2005 to 2018. Regression models adjusting for patient demographics, hospital factors, and clinical severity were used to compare outcomes following MT in patients with and without LVAD. Subgroup analyses were also performed in LVAD patients experiencing stroke in the post-operative setting and stroke in the setting of pre-existing devices.

RESULTS

Of the 1,633,234 AIS hospitalizations identified, 794 occurred in patients with LVADs. Around 61% were post-operative. Post-stroke in-hospital mortality was higher among patients with LVADs (23.3% vs 7.23%, P < 0.001). Among those receiving MT, mortality was also higher in the LVAD population (31.0% vs 14.1%, P = 0.009), though this was largely driven by the post-operative LVAD subgroup. In multivariable analysis, only post-operative LVAD patients experienced greater odds of in-hospital death after MT (adjusted odds ratio (aOR): 8.66, confidence interval (CI):1.46-51.3); patients with pre-existing LVADs demonstrated no difference in post-MT mortality (aOR: 1.06; 95% CI: 0.29-3.91) or in odds of discharge home after MT (aOR 0.63, CI: 0.17-2.32).

CONCLUSION

Our data suggest MT is not a futile treatment approach in patients with pre-existing LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Long-Term Benefit of Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with a Left Ventricular Assist Device: A Single-Center Retrospective Study

OBJECTIVE

Left ventricular assist devices (LVADs) are an epoch-making treatment option for patients with severe heart failure; however, the patients occasionally experience severe acute ischemic strokes (AISs). Although mechanical thrombectomy is considered as an effective treatment for severe AIS in patients with LVADs, there remains a paucity of data on the long-term outcomes. This study aimed to investigate the acute-phase efficacy and long-term outcomes of mechanical thrombectomy for AIS patients with LVADs.

METHODS

We retrospectively reviewed 9 cases in 8 patients with LVADs who developed AIS and underwent mechanical thrombectomy from July 2014 to November 2021 at our hospital. Clinical information, including the National Institutes of Health Stroke Scale score and modified Rankin Scale score before and after thrombectomy, the details of procedures, and the long-term outcomes after thrombectomy, was retrospectively reviewed and statistically analyzed.

RESULTS

Effective recanalization was achieved in 89% of the 9 cases. The median National Institutes of Health Stroke Scale score improved from 12 (range, 8-29) to 5 (range, 0-29) after mechanical thrombectomy. The median total follow-up duration was 1327 (range, 78-2659) days. Of the 8 patients, 3 patients underwent heart transplantation, and the LVAD was removed after recovery of the patient's heart function. One patient awaited heart transplantation.

CONCLUSIONS

This study revealed the long-term benefit of mechanical thrombectomy for AIS in patients with LVADs, eventually achieving 50% of independence from LVADs.

Mechanical Thrombectomy for M1 Subocclusive Thrombus With Lateral Lenticulostriate Artery Occlusion: A Case Report and Literature Review

The treatment for middle cerebral artery subocclusive thrombi is not standardized. Here, we report a case of M1 subocclusive thrombus with lateral lenticulostriate artery occlusion that was successfully treated with mechanical thrombectomy. This article describes a treatment strategy for M1 subocclusive thrombus, focusing on the indications for mechanical thrombectomy. A 58-year-old male on admission for pneumonia had a sudden onset of dysarthria and motor deficits. He has a history of dilated cardiomyopathy and underwent left ventricular assist device implantation 3 years ago. At onset, his National Institutes of Health Stroke Scale (NIHSS) score was nine. Computed tomography angiography demonstrated a filling defect in the distal right M1 segment of the middle cerebral artery. Angiography confirmed the presence of a subocclusive thrombus within the distal right M1 segment, although peripheral blood flow was maintained. Mechanical thrombectomy was performed for the M1 subocclusive thrombus using a direct aspiration first-pass technique, resulting in successful aspiration of the thrombus on the first pass. After the procedure, recanalization of the lateral lenticulostriate artery was detected, and the patient demonstrated full recovery (NIHSS score 0). Mechanical thrombectomy can be considered as a treatment option in cases of acute ischemic stroke caused by M1 subocclusive thrombus with lateral lenticulostriate artery occlusion, which presents with a high NIHSS score or neurological deterioration.

Neurocritical Care of Mechanical Circulatory Support Devices

PURPOSE OF REVIEW

Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population.

RECENT FINDINGS

We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device-associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.

Late Pediatric Mechanical Thrombectomy for Embolic Stroke as Bridge Reinforcement From LVAD to Heart Transplantation

Although the left ventricular assist device is an important bridge to heart transplantation for patients with end-stage heart failure, it can also be a source of embolic stroke. We present a case of late intracranial mechanical thrombectomy performed for embolic stroke beyond the recommended 6 h, thus allowing for heart transplantation 4 days after intracranial mechanical thrombectomy. (Level of Difficulty: Advanced.)

Management of Ischemic Stroke Following Left Ventricular Assist Device

BACKGROUND

Acute ischemic stroke is a common complication and an important source of morbidity and mortality in patients with left ventricular assist devices. There are no standardized protocols to guide management of ischemic stroke among patients with left ventricular assist device. We evaluated our experience treating patients who had an acute ischemic stroke following left ventricular assist device placement.

METHODS

We retrospectively reviewed all patients who underwent left ventricular assist device placement from 2010-2019 and identified patients who had acute ischemic stroke following left ventricular assist device placement.

RESULTS

Of 216 patients having left ventricular assist device placement (mean±SD age 52.9±16.2 years, women 26.9%), 19 (8.8%) had acute ischemic stroke (mean±SD age 55.8±12.0 years, women 36.8%). Median (interquartile range) time to ischemic stroke following left ventricular assist device placement was 96 (29-461) days. At the time of the ischemic stroke, 16/19 (84.2%) patients were taking both antiplatelet and anticoagulation therapy, 1/19 (5.3%) patient was receiving only anticoagulants, 1/19 (5.3%) patient was taking aspirin and dipyridamole, and 1/19 (5.3%) patient was not taking antithrombic agents. INR was subtherapeutic (INR<2.0) in 7/17 (41.2%) patients. No patient was eligible to receive thrombolytic therapy, while 5/19 (26.3%) underwent mechanical thrombectomy. Anticoagulation was continued in the acute stroke phase in 11/19 (57.9%) patients and temporarily held in 8/19 (42.1%) patients. Hemorrhagic transformation of the ischemic stroke occurred in 6/19 (31.6%) patients. Anticoagulation therapy was continued following ischemic stroke in 4/6 (66.7%) patients with hemorrhagic transformation.

CONCLUSIONS

While thrombolytic therapy is frequently contraindicated in the management of acute ischemic stroke following left ventricular assist device, mechanical thrombectomy remains a valid option in eligible patients. Anticoagulation is often continued through the acute phase of ischemic stroke secondary to concerns for LVAD thrombosis. The risks and benefits of continuing anticoagulation must be weighed carefully, especially in patients with large infarct volume, as hemorrhagic transformation remains a common complication.

Mechanical thrombectomy in acute ischemic stroke patients with left ventricular assist device

OBJECTIVES

As the number of patients with left ventricular assist device (LVAD) implantation has been increasing, treatment of LVAD-related ischemic stroke is becoming a critical issue. We sought to clarify the features of mechanical thrombectomy in LVAD-related stroke with large vessel occlusion.

METHODS

In a multi-center, retrospective case-control study, we compared 20 LVAD-related strokes with 33 non-LVAD strokes, all of which had large vessel occlusion in the anterior circulation treated with mechanical thrombectomy. A comparative histopathological examination of the retrieved thrombi was also performed.

RESULTS

Successful reperfusion was achieved in 75% of the LVAD-related strokes. The time from onset to reperfusion was similar to that of non-LVAD strokes, but the total number of device passes required for reperfusion (median, 2.5 versus 1, P = 0.01) and the incidences of post-procedural parenchymal and subarachnoid hemorrhage (25% versus 3%, P = 0.02 and 55% versus 15%, P = 0.01, respectively) were higher in LVAD-related strokes. Symptomatic intracranial hemorrhage occurred in 4 patients (20%) with LVAD-related strokes. The histopathological analysis revealed that the ratio of erythrocyte components was significantly lower in thrombi retrieved from patients with LVAD-related stroke than in those with non-LVAD stroke (19 ± 6% versus 41 ± 17%, P = 0.01).

CONCLUSIONS

Mechanical thrombectomy is feasible in patients with LVAD-related stroke. However, repetitive device passes are needed to achieve successful reperfusion mainly because of the structurally organized thrombi, and the higher risk of hemorrhagic complications should be considered, while offering this therapeutic alternative.

Sequential Pattern Mining of Longitudinal Adverse Events After Left Ventricular Assist Device Implant

Left ventricular assist devices (LVADs) are an increasingly common therapy for patients with advanced heart failure. However, implantation of the LVAD increases the risk of stroke, infection, bleeding, and other serious adverse events (AEs). Most post-LVAD AEs studies have focused on individual AEs in isolation, neglecting the possible interrelation, or causality between AEs. This study is the first to conduct an exploratory analysis to discover common sequential chains of AEs following LVAD implantation that are correlated with important clinical outcomes. This analysis was derived from 58,575 recorded AEs for 13,192 patients in International Registry for Mechanical Circulatory Support (INTERMACS) who received a continuous-flow LVAD between 2006 and 2015. The pattern mining procedure involved three main steps: (1) creating a bank of AE sequences by converting the AEs for each patient into a single, chronologically sequenced record, (2) grouping patients with similar AE sequences using hierarchical clustering, and (3) extracting temporal chains of AEs for each group of patients using Markov modeling. The mined results indicate the existence of seven groups of sequential chains of AEs, characterized by common types of AEs that occurred in a unique order. The groups were identified as: GRP1: Recurrent bleeding, GRP2: Trajectory of device malfunction & explant, GRP3: Infection, GRP4: Trajectories to transplant, GRP5: Cardiac arrhythmia, GRP6: Trajectory of neurological dysfunction & death, and GRP7: Trajectory of respiratory failure, renal dysfunction & death. These patterns of sequential post-LVAD AEs disclose potential interdependence between AEs and may aid prediction, and prevention, of subsequent AEs in future studies.

Left ventricular assist devices and their complications: A review for emergency clinicians

INTRODUCTION

End stage heart failure is associated with high mortality. However, recent developments such as the ventricular assist device (VAD) have improved patient outcomes, with left ventricular assist devices (LVAD) most commonly implanted.

OBJECTIVE

This narrative review evaluates LVAD epidemiology, indications, normal function and components, and the assessment and management of complications in the emergency department (ED).

DISCUSSION

The LVAD is a life-saving device in patients with severe heart failure. While first generation devices provided pulsatile flow, current LVAD devices produce continuous flow. Normal components include the pump, inflow and outflow cannulas, driveline, and external controller. Complications related to the LVAD can be divided into those that are LVAD-specific and LVAD-associated, and many of these complications can result in severe patient morbidity and mortality. LVAD-specific complications include device malfunction/failure, pump thrombosis, and suction event, while LVAD-associated complications include bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation. Assessment of LVAD function, patient perfusion, and mean arterial pressure is needed upon presentation. Electrocardiogram and bedside ultrasound are key evaluations in the ED. LVAD evaluation and management require a team-based approach, and consultation with the LVAD specialist is recommended.

CONCLUSION

Emergency clinician knowledge of LVAD function, components, and complications is integral in optimizing care of these patients.

Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices

Background

Embolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.

Methods

We retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.

Results

The study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.

Conclusions

Endovascular therapy for acute LVO stroke is feasible even in patients with VAD support.

Thrombectomy of Ventricular Assist Device-Originated Embolic Stroke: A Clinical Decision Model

BACKGROUND AND PURPOSE

The use of ventricular assist devices (VADs) for the treatment of heart failure has become increasingly common. These patients have a considerable risk of cerebral embolism. We describe such a patient and his successful treatment by thrombectomy, compare his attributes with those previously published, and describe the construct of a clinical decision model, whose results bear practical implications for patient management.

METHODS

The details of our patient and his treatment are presented, followed by a literature review of all previously reported similar cases. Using this information, as well as that available from published series, we constructed a probabilistic decision tree, completed all calculations (ie, "folding back"), and, in order to assess the strength of the results, subjected them to multiple independent sensitivity analyses of each of the variables.

RESULTS

The therapeutic success of our case, the 14th reported to date, when combined with previous reports, shows: (1) recanalization times of 184 minutes, (2) "successful" recanalization (ie, TICI = 2b or 3) achieved in 71% of procedures, (3) ultimate functional outcome (ie, mRS = 0-2) achieved in 57% patients, and (4) ultimate successful heart transplantations in 66% of cases. The clinical decision model showed the predicted utility of thrombectomy to be superior to conservative management (3.33 QALY vs. 2.56 QALY, respectively). The sensitivity analyses support the validity of these results.

CONCLUSIONS

In conclusion, thrombectomy appears to be a safe and effective method (and often the only viable one) for urgent treatment of patients with VAD-originated cerebral embolism.

Long-term outcomes following thrombectomy for acute ischemic stroke in patients with a left ventricular assist device: a case series and literature review

BACKGROUND

Left ventricular assist devices (LVADs) were developed for the treatment of patients with severe heart failure (HF) as a bridge to heart transplantation (HT). Although long-term LVAD support results in substantial improvements, their long-term use often leads to severe acute ischemic stroke (AIS). Serious neurological events make it difficult to continue LVAD support, and these patients are excluded as candidates for HT. AIS remains a challenging problem in patients receiving LVAD support. Recently, although thrombectomy has been established in selected patients who are independent, it has not been established in patients who are not completely independent, such as those with LVAD support.

METHODS

We describe four AIS patients with severe HF who were implanted with an LVAD as a bridge to HT. Five mechanical thrombectomies were performed for AIS associated with an LVAD in four patients. A literature review is presented and compared to the present results.

RESULTS

Good recanalization was achieved in all patients. In three cases, marked neurological improvement was observed, and modified Rankin Scale (mRS) scores were maintained without deterioration. The median total follow-up period was 592 days. In one patient, HT was successfully performed after thrombectomy. Currently, two of the patients without neurological deficits are awaiting HT.

CONCLUSIONS

Embolism is a major problem encountered by patients under LVAD support while waiting for an HT. Thrombectomy for AIS associated with LVAD support is a useful and safe treatment modality. It is possible to maintain a reasonable mRS score in patients who are not completely independent.

INTERMACS Analysis of Stroke During Support With Continuous-Flow Left Ventricular Assist Devices: Risk Factors and Outcomes

OBJECTIVES

This study sought to evaluate predictors of stroke during left ventricular assist device (LVAD) support from data available prior to implantation, and quantify stroke-related morbidity and mortality.

BACKGROUND

Stroke is a major complication after LVAD. Pre-implant factors that influence stroke are not well understood.

METHODS

We evaluated all patients in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) who were implanted with continuous flow LVADs from May 1, 2012, to March 31, 2015. Pre-operative risk factors for stroke and stroke incidence, morbidity, and mortality were analyzed.

RESULTS

During the study period, 7,112 patients underwent continuous flow LVAD placement. Median follow-up was 9.79 months (range 0.02 to 34.96 months). Of all patients, 752 (10.57%) had at least 1 stroke, with an incidence rate of 0.123 strokes per patient-year. A total of 447 (51.38%) strokes were ischemic and 423 (48.62%) were hemorrhagic. Patients with hemorrhagic stroke had worse survival than those with ischemic strokes (30-day survival: 45.3% vs. 80.7%; p < 0.001). Of patients with a first stroke, 13% had a second stroke. Pre-implant predictors of stroke were female sex (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.25 to 1.82; p < 0.001), pre-implant systolic blood pressure (HR: 1.01; 95% CI: 1.00 to 1.01; p = 0.002), heparin-induced thrombocytopenia (HR: 3.68; 95% CI: 1.60 to 8.47; p = 0.002), intra-aortic balloon pump (HR: 1.21; 95% CI: 1.01 to 1.46; p = 0.043), and primary cardiac diagnosis (ischemic/other/unknown) (p = 0.040).

CONCLUSIONS

Despite improvements in LVAD technology, stroke-related morbidity and mortality is substantial. Further investigation is necessary to decrease the risk of this devastating complication.

Prevention and Treatment of Thrombotic and Hemorrhagic Complications in Patients Supported by Continuous-Flow Left Ventricular Assist Devices

PURPOSE OF REVIEW

The purpose of this review is to describe the current knowledge in prevention and treatment of thrombotic (pump thrombosis and ischemic stroke) and bleeding (gastrointestinal and hemorrhagic stroke) complications in patients supported by continuous-flow left ventricular assist devices (CF-LVAD).

RECENT FINDINGS

Left ventricular assist devices (LVADs) are now widely used for the management of end-stage heart failure. Unfortunately, in spite of the indisputable positive impact LVADs have on patients, the frequency and severity of complications are limitations of this therapy. Stroke, pump thrombosis, and gastrointestinal bleeding are among the most serious and frequent complications in these patients. The balance between hemorrhagic and thrombotic complications in patients supported with CF-LVAD is difficult as most patients do not necessarily fit a "bleeder" or a "clotter" profile but rather move from one side to the other of the thrombotic/bleeding spectrum. Further research is necessary to better understand the risk factors and mechanisms involved in the development of these complications.