Risk Factors of Neurological Events in Patients Supported with Continuous Flow LVADs

Abstract

Left ventricular assist devices (LVADs) are increasingly used as bridge to transplant (BTT) or destination therapy (DT) in end-stage heart failure. Although LVAD therapy improves clinical outcomes, neurological events including ischemic and hemorrhagic cerebrovascular accidents (ICVAs & HCVAs) are still common complications. The purpose of this study was to identify the risk factors for CVAs in patients implanted with HeartWare LVADs. Patients implanted with LVADs between 2005 and 2019 at a single site were included. ICVAs and HCVAs were assessed, and risk factors including blood pressure management and INR were evaluated. A total of 196 patients were implanted with the HeartWare LVADs as DT or BTT between 2005 and 2019. Patients had a mean age of 51±13 years; 67.9% were male, and the mean number of support days were 291±341. The prevalence of CVAs was 13.8% for ischemic (27 of 196) and 5.1% (10 of 196) for hemorrhagic (p<0.05), with a median age of 53 and 50 respectively. The rate of ICVAs and HCVAs per patient year was 0.90 and 0.27 for the first 30 days post-implant, and dropped to 0.10 and 0.04 after 30 days. CVA's were more prevalent prior to discharge with 56% of ICVAs and 40% of HCVAs occurring during index hospitalization. The mean INR peri-stroke for out-of-hospital ICVAs and HCVAs were 2.1 and 3.2 respectively (p<0.05). The INR time in therapeutic range was 47.2%±23 for patients who suffered an ICVA and 43.7%±21 for HCVA, compared to 51.1%±24 for non-stroke patients (p<0.05). Furthermore, the average mean arterial pressure (MAP) measured up to 90 days prior to the CVA was 79 mmhg for patients who developed ICVAs and 75 mmhg for HCVAs (p=0.37). Both ICVAs and HCVAs are major complications for patients implanted with LVADs. The highest risk occurs during the first 30 days post-implant with most occurring during the index hospitalization. A low INR TTR was associated with risk of developing both ICVAs and HCVAs. Targeting a higher TTR may decrease the risk of CVA's in this high risk patient population.