Risk Factors for Development of Stroke in Patients With Continuous-Flow Left Ventricular Assist Device Support as Destination Therapy.

Abstract

Background: Continuous-flow left ventricular assist devices (LVADs) are increasingly used as destination therapy. Although postimplantation stroke rates have been described in the context of bridge-to-transplant or mixed cohorts, stroke development is not well evaluated in patients who receive continuous-flow LVAD with a destination therapy indication. This report characterizes the stroke profile of a modern institutional cohort of patients undergoing destination therapy and evaluates their risk factors for stroke onset.

Methods: Patients implanted with continuous-flow LVAD as destination therapy at the reporting institution between January 2010 and June 2020 were retrospectively reviewed and analyzed. Stroke was defined as any neurologic deficit caused by an abrupt disruption in cerebral blood flow that did not resolve within 24 hours and that was confirmed by imaging. Terminal outcomes of stroke development and death were assessed using a competing-risks model. Fine-Gray regression was used to evaluate potential predictors of stroke development.

Results: Patients who received continuous-flow LVAD (N = 311) were classified by device type: Heart-Mate II (Abbott; n = 97); HeartMate 3 (Abbott; n = 72); and HeartWare Ventricular Assist Device (Medtronic; n = 42). Thirty-five percent of patients (110/311) developed postoperative atrial fibrillation (AF). Estimated stroke incidence was 15% at 1 year, 24% at 3 years, and 27% at 5 years. According to multivariable Fine-Gray regression, receiving a HeartMate 3 device (subdistribution hazard ratio [HR], 0.41 [95% CI, 0.19-0.90]; P = .03) and amiodarone at discharge (HR, 0.55 [95% CI, 0.33-0.94]; P = .03) were associated with lower stroke risk. Postoperative AF (HR, 1.68 [95% CI, 1.03-2.73]; P = .04) was associated with increased stroke risk.

Conclusion: The HeartMate 3 was associated with decreased stroke rates, but risk remained high for patients who developed postoperative AF. Further investigation into protective strategies and use of amiodarone to treat AF after continuous-flow LVAD implantation is needed.