From the Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
From the Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.).
Stroke. 2018 May;49(5):1197-1203. doi: 10.1161/STROKEAHA.117.020002. Epub 2018 Apr 11.
Left ventricular assist devices (LVADs) have emerged as an effective treatment for patients with advanced heart failure refractory to medical therapy. Post-LVAD strokes are an important cause of morbidity and reduced quality of life. Data on risks that distinguish between ischemic and hemorrhagic post-LVAD strokes are limited. The aim of this study was to determine the incidence of post-LVAD ischemic and hemorrhagic strokes, their association with stroke risk factors, and their effect on mortality.
Data are collected prospectively on all patients with LVADs implanted at Brigham and Women's Hospital. We added retrospectively collected clinical data for these analyses.
From 2007 to 2016, 183 patients (median age, 57; 80% male) underwent implantation of HeartMate II LVAD as a bridge to transplant (52%), destination therapy (39%), or bridge to transplant candidacy (8%). A total of 48 strokes occurred in 39 patients (21%): 28 acute ischemic strokes in 24 patients (13%) and 20 intracerebral hemorrhages in 19 patients (10.3%). First events occurred at a median of 238 days from implantation (interquartile range, 93-515) among those who developed post-LVAD stroke. All but 9 patients (4.9%) were on warfarin (goal international normalized ratio, 2-3.5) and all received aspirin (81-325 mg). Patients with chronic obstructive pulmonary disease were more likely to have an ischemic stroke (odds ratio, 2.96; 95% confidence interval, 1.14-7.70). Dialysis-dependent patients showed a trend toward a higher risk of hemorrhagic stroke (odds ratio, 6.31; 95% confidence interval, 0.99-40.47). Hemorrhagic stroke was associated with higher mortality (odds ratio, 3.92; 95% confidence interval, 1.34-11.45) than ischemic stroke (odds ratio, 3.17; 95% confidence interval, 1.13-8.85).
Stroke is a major cause of morbidity and mortality in patients on LVAD support. Chronic obstructive pulmonary disease increases the risk of ischemic stroke, whereas dialysis may increase the risk of hemorrhagic stroke. Although any stroke increases mortality, post-LVAD hemorrhagic stroke was associated with higher mortality compared with ischemic stroke.
左心室辅助装置（LVAD）已成为治疗对药物治疗无效的晚期心力衰竭患者的有效方法。LVAD 后卒中是发病率和生活质量降低的一个重要原因。区分 LVAD 后缺血性和出血性卒中和确定其风险因素的数据有限。本研究的目的是确定 LVAD 后缺血性和出血性卒中的发生率、其与卒中危险因素的关系以及对死亡率的影响。
前瞻性收集在布莱根妇女医院植入 LVAD 的所有患者的数据。我们还回顾性收集了这些分析的临床数据。
2007 年至 2016 年，183 例患者（中位年龄 57 岁，80%为男性）植入 HeartMate II LVAD，作为心脏移植桥接（52%）、终末期治疗（39%）或心脏移植桥接候选（8%）。39 例患者（21%）共发生 48 例卒中：24 例患者中有 28 例急性缺血性卒中（13%），19 例患者中有 20 例颅内出血（10.3%）。发生 LVAD 后卒中的患者中，首次事件中位数发生在植入后 238 天（四分位距，93-515）。除 9 例患者（4.9%）外，所有患者均服用华法林（目标国际标准化比值 2-3.5），且均服用阿司匹林（81-325mg）。患有慢性阻塞性肺疾病的患者更有可能发生缺血性卒中（比值比，2.96；95%置信区间，1.14-7.70）。需要透析的患者发生出血性卒中的风险呈上升趋势（比值比，6.31；95%置信区间，0.99-40.47）。与缺血性卒中相比，出血性卒中与更高的死亡率相关（比值比，3.92；95%置信区间，1.34-11.45）。
卒中是 LVAD 支持患者发病率和死亡率的主要原因。慢性阻塞性肺疾病增加缺血性卒中的风险，而透析可能增加出血性卒中的风险。尽管任何卒中都会增加死亡率，但与缺血性卒中相比，LVAD 后出血性卒中与更高的死亡率相关。
