1
|
Nozdrzykowski M, Bauer JM, Schulz U, Jawad K, Bireta C, Eifert S, Sandri M, Jozwiak-Nozdrzykowska J, Borger MA, Saeed D. Stroke and pump thrombosis following left ventricular assist device implantation: The impact of the implantation technique. Front Cardiovasc Med 2023; 10:974527. [PMID: 37252124 PMCID: PMC10213891 DOI: 10.3389/fcvm.2023.974527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/20/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Several studies have shown the potential advantage of less-invasive surgery (LIS) for left ventricular assist device (LVAD) implantation. This study aims to determine the impact of LIS on stroke and pump thrombosis events after LVAD implantation. Methods Between January 2015 and March 2021, 335 consecutive patients underwent LVAD implantation using either conventional sternotomy (CS) or the LIS technique. Patient characteristics was prospectively collected. All patients were followed up until October 2021. Logistic multivariate regression and propensity-matched analyses were performed to account for confounding factors. Results A total of 242 patients (F = 32; 13.0%) underwent LVAD implantation with CS and 93 patients (F = 8; 8.6%) with the LIS approach. Propensity matching generated two groups, including 98 patients in the CS group and 67 in the LIS group. Intensive care unit stay for the LIS group patients was significantly shorter than that for the CS group patients [2 (IQR: 2-5) days vs. 4 (IQR: 2-12) days, p < 0.01]. There were no significant differences in the incidence of stroke events (14% in CS vs. 16% in the LIS group; p = 0.6) or in pump thrombosis (6.1% in CS vs. 7.5% in the LIS group; p = 0.8) between the groups. The hospital mortality rate in the matched cohort was significantly lower in the LIS group (7.5% vs. 19%; p = 0.03). However, the 1-year mortality rate showed no significant difference between both groups (24.5% in CS and 17.9% in LIS; p = 0.35). Conclusions The LIS approach for LVAD implantation is a safe procedure with potential advantage in the early postoperative period. However, the LIS approach remains comparable to the sternotomy approach in terms of postoperative stroke, pump thrombosis, and outcome.
Collapse
Affiliation(s)
- Michal Nozdrzykowski
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Jessica-Marie Bauer
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Uwe Schulz
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Khalil Jawad
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian Bireta
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sandra Eifert
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Marcus Sandri
- Department of Cardiology, Leipzig Heart Center, Leipzig, Germany
| | | | - Michael A. Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Diyar Saeed
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| |
Collapse
|
2
|
Suzuki F, Sato H, Akiyama M, Akiba M, Adachi O, Harada T, Saiki Y, Kohzuki M. Changes in the Quality of Life of Patients with Left Ventricular Assist Device and Their Caregivers in Japan: Retrospective Observational Study. TOHOKU J EXP MED 2022; 257:45-55. [PMID: 35354693 DOI: 10.1620/tjem.2022.j016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Fumika Suzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Hiroe Sato
- Health Administration Centerr, Niigata University
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Miki Akiba
- Division of Organ Transplantation, Tohoku University Hospital
| | - Osamu Adachi
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Taku Harada
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| |
Collapse
|
3
|
Plecash AR, Byrne D, Flexman A, Toma M, Field TS. Stroke in Patients with Left Ventricular Assist Devices. Cerebrovasc Dis 2021; 51:3-13. [PMID: 34510039 DOI: 10.1159/000517454] [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: 01/20/2021] [Accepted: 05/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND 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. SUMMARY 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. Key messages: 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.
Collapse
Affiliation(s)
- Alyson R Plecash
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada,
| | - Danielle Byrne
- Division of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alana Flexman
- Division of Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mustafa Toma
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Stroke Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| |
Collapse
|
4
|
Emmanuel S, Jansz P, Hayward C. How well do we understand pulsatility in the context of modern ventricular assist devices? Int J Artif Organs 2021; 44:923-929. [PMID: 33960234 DOI: 10.1177/03913988211012707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Modern ventricular assist devices (VADs) use a continuous flow design. It has been suggested that a lack of pulsatility contributes to a range of adverse outcomes including pump thrombus, gastrointestinal bleeding and stroke. To better assess the role of pulsatility in these adverse events, we first require a clear definition of 'pulsatility' in the setting of a severely impaired ventricle and a modern continuous flow VAD. METHODS A literature review was conducted to elucidate the understanding of pulsatility in modern VAD literature. Search engines used included PUBMED, EMBASE and the Cochrane library. Articles were appraised on three aspects: Whether they mentioned pulsatility; whether they mentioned which pulsatility measure was used and finally which methodology was used to obtain the value. RESULTS Of 354 articles reviewed, only 13 met our broad inclusion criteria. Of these articles, the most cited measure was pulsatility index (PI) - used by 11 of the publications. The methodology used to obtain the value was not uniform and five articles did not clearly state it. Other measures included pulse pressure and surplus haemodynamic energy. The majority of articles did not directly discuss pulsatility in the setting of patient-pump interaction. CONCLUSION Most publications did not provide a definition for pulsatility. In those that did, the most common measure was PI. Measuring PI was not standardised. Few papers addressed the impact of intrinsic ventricular function and arterial compliance on pulsatility. We suggest that future publications adopt a uniform definition which encompasses both patient and pump characteristics.
Collapse
Affiliation(s)
- Sam Emmanuel
- St Vincent's Hospital (Sydney), Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, Australia.,School of Medicine, University of Notre Dame, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Paul Jansz
- St Vincent's Hospital (Sydney), Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, Australia.,School of Medicine, University of Notre Dame, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher Hayward
- St Vincent's Hospital (Sydney), Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia
| |
Collapse
|
5
|
Inamullah O, Chiang YP, Bishawi M, Weiss M, Lutz MW, Blue LJ, Feng W, Milano CA, Luedke M, Husseini NE. Characteristics of strokes associated with centrifugal flow left ventricular assist devices. Sci Rep 2021; 11:1645. [PMID: 33462301 PMCID: PMC7814026 DOI: 10.1038/s41598-021-81445-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/06/2021] [Indexed: 01/06/2023] Open
Abstract
Stroke is a devastating complication of left ventricular assist device (LVAD) therapy. Understanding the characteristics, risk factors and outcomes of strokes associated with the centrifugal flow LVADs is important to devise better strategies for management and prevention. This is a retrospective cohort study at a single US academic medical center. The cohort includes patients who received a first time Heartmate 3 (HM3) or Heartware (HVAD) LVAD between September 2009 through February 2018 and had a stroke while the LVAD was in place. Descriptive statistics were used when appropriate. A logistic regression analysis was used to determine predictors of poor outcome. Out of a total of 247 patients, 12.1% (N = 30, 24 HVAD and 6 HM3) had a stroke (63% ischemic) and 3 of these patients had pump thrombosis. Events per patient year (EPPY) were similar for HVAD and HM3 patients (0.3 ± 0.1). INR was subtherapeutic in 47.4% of ischemic stroke patients and supratherapeutic in 18.2% of hemorrhagic stroke patients. Concurrent infections were more common in the setting of hemorrhagic stroke than ischemic stroke (45.4% vs 5.3%, p = 0.008). Strokes were severe in most cases, with initial NIH stroke scale (NIHSS) higher in HM3 patients compared to HVAD patients (mean 24.6 vs 16) and associated with high in-patient mortality (21.1% of ischemic stroke vs. 88.8% of hemorrhagic stroke). Predictors of death within 30 days and disability at 90 days included creatinine at stroke onset, concurrent infection, hemorrhaghic stroke, and initial stroke severity (NIHSS). A score derived from these variables predicted with 100% certainty mortality at 30 days and mRS ≥ 4 at 90 days. For patients with centrifugal flow LVADs, ischemic strokes were more common but hemorrhagic strokes were associated with higher in-patient mortality and more frequently seen in the setting of concurrent infections. Infections, sub or supratherapeutic INR range, and comorbid cardiovascular risk factors may all be contributing to the stroke burden. These findings may inform future strategies for stroke prevention in this population.
Collapse
Affiliation(s)
- Ovais Inamullah
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Yuting P Chiang
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Martin Weiss
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Michael W Lutz
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Laura J Blue
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Wayne Feng
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Matthew Luedke
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Nada El Husseini
- Department of Neurology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| |
Collapse
|
6
|
Mechanical thrombectomy in acute ischemic stroke patients with left ventricular assist device: More information, more evidence. J Neurol Sci 2020; 421:117192. [PMID: 33162064 DOI: 10.1016/j.jns.2020.117192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/16/2020] [Indexed: 11/24/2022]
|
7
|
Whitaker-Lea WA, Toms B, Toms JB, Shah KB, Quader M, Tang D, Kasirajan V, Rivet DJ, Reavey-Cantwell JF. Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review. World Neurosurg 2020; 139:e635-e642. [DOI: 10.1016/j.wneu.2020.04.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 01/11/2023]
|
8
|
Tsiouris A, Heliopoulos I, Mikroulis D, Mitsias PD. Stroke after implantation of continuous flow left ventricular assist devices. J Card Surg 2019; 34:541-548. [DOI: 10.1111/jocs.14079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/13/2019] [Accepted: 04/18/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Athanasios Tsiouris
- Department of Cardiothoracic SurgeryProvidence Medical CenterKansas City Kansas
| | - Ioannis Heliopoulos
- Department of Neurology, University Hospital of AlexandroupolisSchool of MedicineDemocritus University of ThraceAlexandroupolis Greece
| | - Dimitrios Mikroulis
- Department of Cardiothoracic Surgery, University Hospital of Alexandroupolis, School of MedicineDemocritus University of ThraceAlexandroupolis Greece
| | - Panayiotis D. Mitsias
- Department of Neurology, University Hospital of HeraklionUniversity of Crete Greece
- Department of Neurology & Comprehensive Stroke CenterHenry Ford HospitalDetroit Michigan
| |
Collapse
|
9
|
Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider. J Emerg Med 2019; 56:611-623. [PMID: 31003823 DOI: 10.1016/j.jemermed.2019.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs). OBJECTIVE This review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context. DISCUSSION With a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population. CONCLUSIONS The cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.
Collapse
|
10
|
Shaban A, Leira EC. Neurological Complications of Cardiological Interventions. Curr Neurol Neurosci Rep 2019; 19:6. [DOI: 10.1007/s11910-019-0923-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
11
|
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, The Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|