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Neurologic Complications in Patients With Left Ventricular Assist Devices. Can J Cardiol 2023; 39:210-221. [PMID: 36400374 PMCID: PMC9905352 DOI: 10.1016/j.cjca.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.
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2
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Hernandez NS, Kanter M, Sharma V, Wang A, Kiernan M, Kryzanski D, Heller R, Nail T, Riesenburger RI, Kryzanski JT. Radiographic risk factors for intracranial hemorrhage in patients with left ventricular assist devices. J Stroke Cerebrovasc Dis 2022; 31:106869. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/07/2022] Open
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3
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Pivazyan G, Rock M, Dowlati E, Mai J, Mason R. Treatment of chronic subdural hematoma in a patient with a left ventricular assist device: Case report and review of the literature. Brain Circ 2022; 8:64-67. [PMID: 35372729 PMCID: PMC8973450 DOI: 10.4103/bc.bc_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/09/2021] [Accepted: 12/18/2021] [Indexed: 11/26/2022] Open
Abstract
Patients with left ventricular assist devices (LVADs) provide a unique challenge with regard to the management of subdural hematomas (SDH), due to preexisting comorbidities and induced coagulopathy. We report on the case of a 63-year-old female with a preexisting LVAD who developed an acute on chronic SDH with 15 mm of midline shift. She was successfully treated with middle meningeal artery (MMA) embolization and placement of a bedside subdural evacuating port system without hematoma recurrence at 1-year follow-up. Both operative and nonoperative management of SDHs in patients with LVAD is associated with high risk of mortality and morbidity. Chronic SDHs in this patient population can be successfully managed with a minimally invasive approach that includes MMA embolization and bedside subdural drain placement.
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4
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Chen J, Gong J, Chen H, Li X, Wang L, Qian X, Zhou K, Wang T, Jiang S, Li L, Li S. Ischemic stroke induces cardiac dysfunction and alters transcriptome profile in mice. BMC Genomics 2021; 22:641. [PMID: 34481466 PMCID: PMC8418010 DOI: 10.1186/s12864-021-07938-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 08/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background Stroke can induce cardiac dysfunction in the absence of primary cardiac disease; however, the mechanisms underlying the interaction between the neurological deficits and the heart are poorly understood. The objective of this study was to investigate the effects of stroke on cardiac function and to identify the transcriptome characteristics of the heart. Results Stroke significantly decreased heart weight/tibia length ratio and cardiomyocyte cross-sectional areas and increased atrogin-1 and the E3 ubiquitin ligase MuRF-1, indicating myocardial atrophy in MCAO-induced mouse hearts. RNA sequencing of mRNA revealed 383 differentially expressed genes (DEGs) in MCAO myocardium, of which 221 were downregulated and 162 upregulated. Grouping of DEGs based on biological function and quantitative PCR validation indicated that suppressed immune response and collagen synthesis and altered activity of oxidoreductase, peptidase, and endopeptidase may be involved in MCAO-induced cardiomyopathy. The DEGs were mainly distributed in the membrane or extracellular region of cardiomyocytes and acted as potential mediators of stroke-induced cardiac dysregulation involved in cardiac atrophy. Conclusion Stroke induced a unique transcriptome response in the myocardium and resulted in immediate cardiac atrophy and dysfunction. Supplementary Information The online version contains supplementary material available at 10.1186/s12864-021-07938-y.
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Affiliation(s)
- Jie Chen
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiahong Gong
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Haili Chen
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Xuqing Li
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Li Wang
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Xiaoli Qian
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Kecheng Zhou
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Ting Wang
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Songhe Jiang
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Lei Li
- Institute of Cardiovascular Development and Translational Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shengcun Li
- Rehabilitation Medicine Center, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China. .,Integrative & Optimized Medicine Research center, China-USA Institute for Acupuncture and Rehabilitation, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China. .,Institute of Cardiovascular Development and Translational Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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5
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Cho SM, Tahsili-Fahadan P, Kilic A, Choi CW, Starling RC, Uchino K. A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke. Semin Neurol 2021; 41:411-421. [PMID: 33851393 DOI: 10.1055/s-0041-1726328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.
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Affiliation(s)
- Sung-Min Cho
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pouya Tahsili-Fahadan
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, Inova Fairfax Medical Campus, Falls Church, Virginia.,Neuroscience Research, Neuroscience and Spine Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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6
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Shoskes A, Whitman G, Cho SM. Neurocritical Care of Mechanical Circulatory Support Devices. Curr Neurol Neurosci Rep 2021; 21:20. [PMID: 33694065 DOI: 10.1007/s11910-021-01107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Division of Neuroscience Critical Care, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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7
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Shaban A, Leira EC. Neurologic complications of heart surgery. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:65-75. [PMID: 33632458 DOI: 10.1016/b978-0-12-819814-8.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cardiac surgeries are commonly associated with neurologic complications. The type and complexity of the surgery, as well as patients' comorbidities, determine the risk for these complications. Awareness and swift recognition of these complications may have significant implications on management and prognosis. Recent trials resulted in an expansion of the time window to treat patients with acute ischemic stroke with intravenous thrombolysis and/or mechanical thrombectomy using advanced neuroimaging for screening. The expanded time window increases the reperfusion treatment options for patients that suffer a periprocedural ischemic stroke. Moreover, there is now limited data available to help guide management of intracerebral hemorrhage in patients undergoing treatment with anticoagulation for highly thrombogenic conditions, such as left ventricular assist devices and mechanical valves. In addition to cerebrovascular complications patients undergoing heart surgery are at increased risk for seizures, contrast toxicity, cognitive changes, psychological complications, and peripheral nerve injuries. We review the neurological complications associated with the most common cardiac surgeries and discuss clinical presentation, diagnosis and management strategies.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.
| | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, United States
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8
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Gyoten T, Rojas SV, Irimie A, Schramm R, Morshuis M, Gummert JF, Sitzer M, Fox H. Patients with ventricular assist device and cerebral entrapment-Supporting skullcap reimplantation. Artif Organs 2020; 45:473-478. [PMID: 33141976 DOI: 10.1111/aor.13856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all-cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge-to-transplantation LVAD patients [median age at LVAD implantation: 32.5 years (IQR: 24.8-39.5 years); four male, HVAD, n = 3; HM II, n = 1; HM 3, n = 2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n = 2), dilated (n = 2), or ischemic (n = 2). Median INTERMACS class was 1.5 (IQR; 1.0-2.8). Median time on LVAD support to DC procedure was 33 months (IQR: 16-48 months). The indication for DC was intraparenchymal hemorrhage (n = 4), subdural hematoma (n = 1), and malignant middle cerebral artery infarction (n = 1). After a median time of 4 months (IQR: 3.3-4.0 months, range; 2.0-10 months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26 months (IQR: 21-42 months) follow-up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis.
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Affiliation(s)
- Takayuki Gyoten
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Sebastian V Rojas
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Anca Irimie
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Department of Neurology, Klinikum Herford, Herford, Germany
| | - René Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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9
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Carroll AH, Ramirez MP, Dowlati E, Mueller KB, Borazjani A, Chang JJ, Felbaum DR. Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 30:105501. [PMID: 33271486 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. METHODS A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. RESULTS 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) subarachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.10-1.91, p = 0.01) for ICH patients undergoing surgical intervention. The hemorrhage subtype most frequently managed with anticoagulation reversal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. CONCLUSION Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to contribute to management and prognostication .
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Affiliation(s)
| | | | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA.
| | - Kyle B Mueller
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, R.I., USA
| | - Ali Borazjani
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, D.C., USA; Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA
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10
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Clinically Silent Brain Injury and Perioperative Neurological Events in Patients With Left Ventricular Assist Device: A Brain Autopsy Study. ASAIO J 2020; 67:917-922. [PMID: 33229972 DOI: 10.1097/mat.0000000000001317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Current studies underestimate the prevalence of brain injury in patients with left ventricular assist devices (LVADs), as CT scans are not sensitive in detecting cerebral ischemia. Using postmortem neuropathological evaluation, we sought to characterize the types and risk factors of brain injury in LVAD patients. We reviewed 24 LVAD patients who underwent brain autopsy with gross and microscopic examinations from 1993 through 2019 at a single tertiary center. Patients who expired less than 7 days after implantation or who underwent explantation more than 7 days before death were excluded. Our study demonstrated that all LVAD nonsurvivors developed brain injury. The most common brain injury was hemorrhage (71%), followed by infarct (42%) and hypoxic ischemic brain injury (HIBI) (33%), and 10 patients (42%) presented with more than 1 brain injury. Cerebral microbleeds (CMBs) and intracranial hemorrhage were present in 33% and 42%, respectively. In those with intracranial hemorrhage, subarachnoid hemorrhage (25%) and intracerebral hemorrhage (25%) were more common than subdural hematoma (4%). Intracranial hemorrhage was associated with driveline infection (P = 0.047), and HIBI was associated with prior history of chronic obstructive pulmonary disease (P = 0.037). Fourteen (60%) had clinically silent brain injury with 65% of hemorrhages and 70% of infarcts being silent. However, the impact of silent brain injury on neurologic outcome and mortality remains unclear. Standardized neurologic monitoring and surveillance are recommended to better detect these clinically silent brain injury.
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11
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Abstract
Abstract
Left ventricular assist device (LVAD) has emerged as a safe, durable, and revolutionary therapy for end-stage heart failure patients. Despite the appearance of newer-generation devices that have improved patient outcomes, the burden of adverse events remains significant. Although the survival rate for patients with LVAD is appreciated to be 81% at 1 year and 70% at 2 years, the incidence of adverse events is also high. Over time, both early and late postimplant complications have diminished in terms of prevalence and impact; however, complications, such as infections, bleeding, right heart failure, pump thrombosis, aortic insufficiency, or stroke, continue to represent a challenge for the practitioner. Therefore, the aim of this review is to highlight the most recent data regarding the current use of LVAD in the treatment of end-stage heart failure, with a specific focus on LVAD-related complications, in order to improve device-related outcomes. It will also revise how to mitigate the risk and how to approach specific adverse events. Withal, understanding the predisposing risk factors associated with postimplant complications, early recognition and appropriate treatment help to significantly improve the prognosis for patients with end-stage heart failure.
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12
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Bonderski VA, Portillo J, Sharp L, Rech MA. Thromboelastometry-guided anticoagulation reversal in a patient with ventricular assist device with intracranial hemorrhage. Am J Emerg Med 2020; 41:265.e5-265.e8. [PMID: 33010991 DOI: 10.1016/j.ajem.2020.08.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 01/24/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a known complication in patients with ventricular assist devices (VAD). We present a case of a 42-year-old male with a VAD and on warfarin who presented to the emergency department with ICH necessitating anticoagulant reversal. An attenuated dose of 15 units/kg of 4-factor prothrombin complex-concentrates (4F-PCC) was given and the patient's coagulation profile was subsequently assessed using rotational thromboelastometry (ROTEM®) to determine appropriateness of reversal. ROTEM® analysis showed adequate reversal at the time of assessment and the patient ultimately returned home without further functional deficits, highlighting the role of ROTEM® to guide anticoagulation reversal in the VAD patient population.
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Affiliation(s)
- Veronica A Bonderski
- Department of Pharmacy, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, United States.
| | - Josue Portillo
- Department of Emergency Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, United States.
| | - Lydia Sharp
- Department of Emergency Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, United States.
| | - Megan A Rech
- Department of Emergency Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, United States.
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13
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Zima LA, Fotso CM, Parikh V, Sheinberg D, Monterey M, Choi HA, Kitagawa R. Cerebral hemorrhage in the LVAD patient: A case series and literature review. Clin Neurol Neurosurg 2020; 197:106094. [DOI: 10.1016/j.clineuro.2020.106094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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14
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Melmed KR, Mondellini G, Roh D, Boehme A, Park S, Yuzefpolkya M, Naka Y, Uriel N, Agarwal S, Connolly ES, Claassen J, Colombo PC, Willey JZ. Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients. World Neurosurg 2020; 143:e384-e390. [PMID: 32745643 DOI: 10.1016/j.wneu.2020.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality. METHODS We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome. RESULTS Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study's inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL3 (interquartile range [IQR], 8.6-46.9 mL3), and the median ICH score was 1 (IQR, 1-2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4-4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4-6.2). CONCLUSIONS HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.
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Affiliation(s)
- Kara R Melmed
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, New York, USA; Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.
| | - Giulio Mondellini
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - David Roh
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Amelia Boehme
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Melana Yuzefpolkya
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sachin Agarwal
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Jan Claassen
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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