Morgan Jeffrey A, Brewer Robert J, Nemeh Hassan W, Gerlach Brent, Lanfear David E, Williams Celeste T, Paone Gaetano
From the *Division of Cardiothoracic Surgery and †Division of Cardiovascular Medicine, Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan.
ASAIO J. 2014 May-Jun;60(3):284-9. doi: 10.1097/MAT.0000000000000074.
Development of stroke while on left ventricular assist device (LVAD) support can be a source of significant morbidity and mortality. From March 2006 through November 2011, one hundred patients with chronic heart failure underwent implantation of a HeartMate II (HM II) LVAD (Thoratec Corp.) as a bridge to transplant (BTT; n = 65) or destination therapy (DT; n = 35). Records were reviewed to determine the prevalence and type of postimplant stroke, anatomic cerebral location of strokes, and associated morbidity and mortality. Cox multivariate logistic regression analysis was conducted to identify independent predictors of postoperative stroke. Strokes occurred in 12 patients (12.0%): four embolic and eight hemorrhagic. Median duration of support at the time of stroke was 281.0 days for embolic strokes and 380.5 days for hemorrhagic strokes (p = 0.028). Stroke patients had a significantly higher incidence of diabetes (66.7% vs. 40.9%; p = 0.024), history of preimplant stroke (16.7% vs. 4.5%; p = 0.046), and aortic cross-clamping with cardioplegic arrest during their LVAD implant (50.0% vs. 20.2%; p = 0.034) compared with patients without postoperative strokes. Mean international normalized ratio (INR) at the time of stroke was subtherapeutic in all four patients with embolic strokes (mean: 1.5 ± 0.1 IU; range 1.3-1.6 IU) and supratherapeutic in four of eight patients with hemorrhagic strokes (mean: 3.2 ± 2.2 IU, range: 1.4-7.0 IU; p = 0.024). There was a 25.0% 30 day mortality after stroke. Diabetes (odds ratio [OR] 6.36; p = 0.029), aortic cross-clamping with cardioplegic arrest (OR 4.75; p = 0.025), duration of LVAD support (OR 1.00; p = 0.008), and INR (OR 4.42; p = 0.020) were independent predictors of stroke in multivariate analysis with a trend toward significance for history of stroke (OR 6.25; p = 0.075). Stroke represented an important source of morbidity and mortality for patients on HM II LVAD support. As long-term device therapy continues to gain popularity for both BTT and DT, a better understanding of the predictors of stroke, more strict control of postoperative anticoagulation, and the establishment of a risk stratification model may aid in minimizing its occurrence.
在左心室辅助装置（LVAD）支持下发生中风可能是导致严重发病和死亡的原因。从2006年3月至2011年11月，100例慢性心力衰竭患者接受了HeartMate II（HM II）LVAD（Thoratec公司）植入，作为移植桥接（BTT；n = 65）或终末期治疗（DT；n = 35）。回顾记录以确定植入后中风的发生率和类型、中风的脑解剖位置以及相关的发病率和死亡率。进行Cox多变量逻辑回归分析以确定术后中风的独立预测因素。12例患者（12.0%）发生中风：4例为栓塞性中风，8例为出血性中风。中风时的中位支持时间，栓塞性中风为281.0天，出血性中风为380.5天（p = 0.028）。与未发生术后中风的患者相比，中风患者的糖尿病发病率显著更高（66.7%对40.9%；p = 0.024）、植入前有中风病史（16.7%对4.5%；p = 0.046）以及在LVAD植入期间进行主动脉交叉阻断并心脏停搏（50.0%对20.2%；p = 0.034）。所有4例栓塞性中风患者中风时的平均国际标准化比值（INR）低于治疗水平（平均：1.5±0.1 IU；范围1.3 - 1.6 IU），8例出血性中风患者中有4例高于治疗水平（平均：3.2±2.2 IU，范围：1.4 - 7.0 IU；p = 0.024）。中风后30天死亡率为25.0%。在多变量分析中，糖尿病（优势比[OR] 6.36；p = 0.029）、主动脉交叉阻断并心脏停搏（OR 4.75；p = 0.025）、LVAD支持时间（OR 1.00；p = 0.008）和INR（OR 4.42；p = 0.020）是中风的独立预测因素，中风病史有显著趋势（OR 6.25；p = 0.075）。中风是接受HM II LVAD支持患者发病和死亡的重要原因。随着长期装置治疗在BTT和DT中越来越普遍应用，更好地了解中风的预测因素、更严格地控制术后抗凝以及建立风险分层模型可能有助于减少其发生。
