Abstract
Background and purpose: The study aims to identify the characteristics and neurological outcomes of the left ventricular-assist device (LVAD)-associated cerebrovascular events (CVE) and infections, particularly in the setting of infectious intracranial aneurysms (IIA).Methods: A single-center retrospective review of patients having undergone LVAD implantation between 2011 and 2017 was conducted using institutional registries and screened for CVE. Patients with CVE were assessed for concurrent bacteremia; neurovascular imaging was then used to isolate patients with IIA. A review of comorbidities, imaging characteristics, and management were performed to determine predictors of neurological outcomes, as defined by the 90-day modified Rankin scale (mRS) scores.Results: Of the 383 HeartMate II LVAD implantations performed, 43 all-cause stroke events were identified across 35 (9%) patients. The majority of the events were hemorrhagic CVE (n=28) with 21 events complicated by bacteremia. Of patients with hemorrhagic CVE and bacteremia, Staphylococcus aureus (n=10) and Pseudomonas aeruginosa (n= 8) infection were the most frequently associated organisms. Severe disability or death (90-day mRS > 4) was observed in 15 patients (63%). Seven patients had confirmed findings of IIA on diagnostic cerebral angiogram and were associated with distal middle cerebral artery (MCA) territory involvement (n=6; 86%) with concurrent Staphylococcus (n=5, 71%) and/or Pseudomonas (n=4, 57%) infections. Overall, a higher incidence of acute and chronic bacteremia was observed in the hemorrhagic CVE subgroup compared to the ischemic CVE subgroup (74% vs 36% & 71% vs 29%, respectively; p <0.05). Despite endovascular and/or surgical intervention in patients with IIA, four patients failed management and elected for comfort measures.Conclusion: Our results indicate that P. aeruginosa and S. aureus bacteremia are associated with a greater incidence of intracranial hemorrhage and worse neurological outcomes. Future management considerations may include pre-implantation cerebrovascular imaging to assess vascular pathology including prior aneurysms and intracranial atherosclerotic disease burden as a screen for higher-risk patients, as well as more aggressive antibiotic therapy at bacteremia onset.
Highlights
Left ventricular-assist devices (LVAD) have been established as temporary options as a bridge to heart transplants and as a destination therapy for patients who may not be transplant candidates [1,2]
Our results indicate that P. aeruginosa and S. aureus bacteremia are associated with a greater incidence of intracranial hemorrhage and worse neurological outcomes
There was a higher incidence of acute bacteremia (73% vs 35%; p
Summary
Left ventricular-assist devices (LVAD) have been established as temporary options as a bridge to heart transplants and as a destination therapy for patients who may not be transplant candidates [1,2]. Cerebrovascular events (CVE) and infection are among the most common complications of LVAD therapy leading to higher rates of morbidity and mortality [3]. The incidence of LVAD-associated IIA is not well defined, higher mortality has been anecdotally reported. There is a paucity of data defining the characteristics and neurological outcomes of LVAD-associated CVEs and infections, in the setting of IIAs. A retrospective observational study was conducted to help identify specific patient characteristics which may be associated with a higher risk of cerebrovascular complications due to IIAs and to suggest preventative. The study aims to identify the characteristics and neurological outcomes of the left ventricular-assist device (LVAD)-associated cerebrovascular events (CVE) and infections, in the setting of infectious intracranial aneurysms (IIA)
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