Cerebrovascular Accident in a Patient with Left Ventricular Assist Device and Therapeutic INR: Should Left Atrial Appendage Be Routinely Closed?

Abstract

Introduction Left ventricular assist device (LVAD) as a destination therapy (DT) is considered one of the main therapeutic strategies in patients with end-stage CHF. Postoperative (post-op) a-fib can develop in LVAD patients placing them at risk of developing cerebrovascular accident (CVA) from left atrial appendage (LAA) thrombus. We present a case of LVAD patient with a new post-op a-fib who developed embolic CVA from LAA thrombus despite having therapeutic INR. In addition, we discuss whether LAA should be precautionary closed during LVAD implantation to prevent such complication. Case A 64-year-old female with a medical history of advanced ischemic HFrEF (EF 10-15%) status post-LVAD as DT, postoperative a-fib, uncontrolled DM II who presented with slurred speech and left-sided weakness. Last known well time was 16 hours ago. CT head showed hypodensity in the right centrum semiovale figure 1A. CT angiogram head showed a filling defect in the right middle cerebral artery figure 1B. The patient was diagnosed with acute embolic ischemic CVA. She did not have a-fib before her LVAD. However, during her post-op day 2, she developed a new onset-afib requiring amiodarone and digoxin besides warfarin. She was maintained on therapeutic INR post-LVAD except for a period of sub-therapeutic INR of 14 days that was bridged with LMWH figure 1C. TEE revealed LAA thrombus figure 1D which was identified as the embolic source. Physical therapy (PT) worked with the patient in the hospital and after being discharged. She continued to follow up at the HF clinic with gradual functional improvement. Discussion The patient's LDH post-LVAD remained at its post-op range between 603 and 952 U/L without peaking, other acute hemolysis indices were negative, and LVAD did not give any alarm. All of that excluded LVAD thrombus as a culprit and confirmed that the LAA thrombus was the CVA source. It was felt that if LAA closure was done during the patient's LVAD surgery, it would have prevented her CVA. However, the absence of previous a-fib, embolic CVA, or venous thromboembolic event at the time of surgery did not give the surgical team any hint to consider the LAA closure. Conclusion Patients with LVAD and therapeutic INR remain at risk of forming a thrombus in the LAA and having cardio-embolic CVA. Pending further research focused on cardio-embolic profiling, the role of LAA closure during LVAD implantation surgery should be considered on a case-to-case basis.