Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, Netherlands.
Eur J Cardiothorac Surg. 2012 Oct;42(4):612-20. doi: 10.1093/ejcts/ezs320. Epub 2012 Jun 1.
Left ventricular assist devices (LVADs) are increasingly being used as a bridge to heart transplantation or destination therapy. It is unclear which antithrombotic regimen should be used to reduce the risk of stroke. We systematically reviewed the literature on all types of antithrombotic regimens and stroke in patients with any type of LVADs. Our primary outcome measure was the mean incidence of any type of stroke. Twenty-six articles were selected as relevant, comprehending 1989 patients with a mean LVAD support of 200 days (range 30-621). The mean proportion of patients affected with stroke was 20% (range 0-55%), with a mean incidence of 0.74 (range 0-6.91) events/patient-year. Support with HeartMate II and a regimen of postoperative heparin converted to coumarins, acetylsalicylic acid (ASA) and dipyridamole resulted in 0.17 (mean; range 0.06-0.29) strokes/patient-year. HeartMate II support and the same regime without heparin was associated with 0.07 (mean; range 0.03-0.11) strokes/patient-year. A Novacor device with heparin, converted to coumarins, was associated with 3.82 (mean; range 1.03-6.91) strokes/patient-year, while ASA added to this regime resulted in 0.97 ischaemic strokes/patient-year (mean; range 0.53-1.48). Other combinations of assist devices and antithrombotic regimes were investigated in one or two studies only. This systematic review provides risk estimates for stroke for various LVADs and antithrombotic regimes. Our findings indicate that the postoperative use of heparin in HeartMate II patients is doubtful, and suggest an important role for antiplatelet drugs to prevent stroke in patients supported with a Novacor device.
左心室辅助装置（LVADs）越来越多地被用作心脏移植或终末期治疗的桥梁。目前尚不清楚哪种抗血栓治疗方案可以用来降低中风的风险。我们系统地回顾了所有类型的抗血栓治疗方案和 LVAD 患者中风的文献。我们的主要观察指标是任何类型中风的平均发生率。选择了 26 篇相关文章，共纳入 1989 例 LVAD 支持平均 200 天（范围 30-621 天）的患者。患有中风的患者比例平均为 20%（范围 0-55%），平均每年发生率为 0.74（范围 0-6.91）例/患者。使用 HeartMate II 支持和术后肝素转换为香豆素、乙酰水杨酸（ASA）和双嘧达莫的方案导致每年每例患者发生 0.17 次（平均；范围 0.06-0.29）中风。使用 HeartMate II 支持且无肝素的同一方案与每年每例患者发生 0.07 次（平均；范围 0.03-0.11）中风相关。使用肝素转换为香豆素、ASA 的 Novacor 装置与每年每例患者发生 3.82 次（平均；范围 1.03-6.91）中风相关，而将 ASA 添加到该方案中会导致每年每例患者发生 0.97 次缺血性中风（平均；范围 0.53-1.48）。其他类型的辅助装置和抗血栓治疗方案仅在一项或两项研究中进行了研究。本系统综述为各种 LVAD 和抗血栓治疗方案的中风风险提供了估计值。我们的研究结果表明，术后使用肝素治疗 HeartMate II 患者是值得怀疑的，并提示抗血小板药物在预防使用 Novacor 装置支持的患者中风方面发挥重要作用。
