Abstract WP391: Management of Ischemic Stroke Following Left Ventricular Assist Device: A Retrospective Case Series

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Introduction: Acute ischemic stroke (AIS) is a common complication and an important source of morbidity and mortality in patients with left ventricular assist devices (LVAD). There are currently no universal protocols to guide management of AIS among patients with LVAD. Management of anticoagulation is challenging, requiring clinicians to balance risk of hemorrhagic transformation vs development of LVAD thrombosis. We sought to evaluate treatment strategies among patients who had an AIS following use of a LVAD. Methods: We retrospectively reviewed all patients who underwent LVAD placement at our institution from 2010-2019. We identified patients who had AIS and extracted clinical data. Results: Of 238 patients having LVAD placement, we identified 19 (7.9%) with AIS (median age 59 years; median NIHSS score 9). Mean interval to AIS following LVAD placement was 405 days (8 days-5.7 years). At initial presentation, 16/19 (84.2%) patients were taking both antiplatelet and anticoagulation therapy, 1/19 (5.3%) was receiving only anticoagulants, 1/19 (5.3%) was taking aspirin and dipyridamole, and 1/19 (5.3%) was not taking antithrombic agents. Mean INR was 2.1 (1.0-3.2). INR was subtherapeutic (INR<2.0) in 8/19 (42.1%). No patient was eligible to receive thrombolytic therapy (therapeutic anticoagulation in 12 patients, delayed presentation in 4, major surgery in 2, and intracerebral hemorrhage in 1), while 5/19 (26.3%) underwent mechanical thrombectomy. Anticoagulation was continued in the acute stroke phase in 11/19 (57.9%); however, anticoagulation was temporarily held in 8/19 (42.1%). Hemorrhagic transformation occurred in 6/19 (32.6%) with median time of 6 days (0-18 days) from onset of AIS. Mean INR at the time of hemorrhagic transformation was 2.6 (1.0-6.0). There was no interruption in anticoagulation in 4/6 (66.7%) patients with hemorrhagic transformation. Median discharge NIHSS was 2 (0-42) and median modified Rankin Scale was 3 (0-6). Conclusions: Thrombolytic therapy is not used in management of AIS in patients with LVAD. Endovascular interventions remain a valid option. Anticoagulation is frequently continued through the acute phase of AIS secondary to concerns for LVAD thrombosis. Hemorrhagic transformation is a common complication.