Stroke in patients with left ventricular assist device (LVAD): Who is at risk? -a retrospective observational study at a tertiary care center

Yasemin Akalan¹Hans Worthmann²Dominik Berliner¹Juliane Hupe³Gerrit M. Grosse⁴Omar Abu-Fares⁵Kim Kristin Ravenberg⁶Karin Weissenborn²Arjang Ruhparwar⁷Steven R. Talbot⁸Johann Bauersachs¹Jan D. Schmitto⁷Jasmin S. Hanke⁷Maria Magdalena Gabriel^2,9*

• ¹Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Hannover, Germany
• ²Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Hannover, Germany
• ³Vascular and Endovascular Surgery Hospital Wolfsburg, Sauerbruchstr. 7, 38440 Wolfsburg, Germany, Wolfsburg, Germany
• ⁴Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
• ⁵Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Hannover, Germany
• ⁶Department of Radiology, Klinikum Osnabrueck, Am Finkenhügel 1, 47076 Osnabrueck, Germany, Osnabrueck, Germany
• ⁷Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Hannover, Germany
• ⁸Institute for Laboratory Animal Science, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Hannover, Germany
• ⁹Hannover Medical School, Hanover, Germany

Objectives: Stroke is a severe complication in patients with left ventricular assist devices (LVAD), significantly affecting quality of life and potentially leading to death. This study aimed to illustrate the clinical features, outcomes, and risk factors associated with stroke in LVAD patients, with the goal of identifying potential treatment targets.Methods: In a study of 249 consecutive patients who underwent LVAD implantation, detailed evaluations were conducted regarding clinical characteristics, perioperative management, cardiovascular risk factors, comorbidities, and brain imaging. The etiology, treatment, and outcomes were subsequently assessed in individuals who encountered a stroke.Results: Eighty-three cerebrovascular events (CVE) occurred in 54/249 patients during a median study period of 2.2 years (0.4-3.5) with 53 ischemic events and 22 intracranial hemorrhages (ICH). Early peri- or postoperatively CVE in context to the LVAD implantation were identified in 31 patients. Competing risks regression analysis revealed that postoperative dialysis was associated with higher risk for CVE, considering death as competing risk event (HR 3.617; 95%-CI: 1.78-7.35; p≤0.001). Modified Rankin Scale at outpatient visit did not differ in early CVE (3 (IQR 2-5) vs. 3 (IQR2-4), p=0.146). Late CVE frequently occurred during hospitalization for sepsis or in cardiac rehabilitation (n=16/41 events (39%)). Competing risk analysis treating death and heart transplantation as competitors identified history of stroke as associated factor (HR 3.564; 95%-CI [1.67-7.169]; p=0.001). Mortality was not associated with CVE (with n=27/54 (50%) vs. without CVE 94/195 (48.2%) p=0.183). Conclusion: Patients who require postoperative dialysis face a heightened risk for early cerebrovascular events (CVE) during and after LVAD implantation. Additionally, a history of stroke and complicated clinical courses should increase awareness regarding the potential for impending CVE in the long term.