Sean D. Lavine, MD
Over the last decade, left ventricular assist devices (LVADs) have transformed the management of patients with advanced heart failure. However, LVADs are associated with the potentially devastating risk of acute ischemic stroke (AIS), of which large vessel occlusions (LVOs) comprise a significant proportion and result in more severe stroke syndromes and worse outcomes. Although mechanical thrombectomy (MT) is an established treatment for LVOs in the general population, the minimally invasive endovascular procedure has not been studied in patients with LVADS. To bridge this knowledge gap, NewYork-Presbyterian/
There was a lot of trepidation among our colleagues that we may be hurting LVAD patients with mechanical thrombectomy due to issues concerning anticoagulation. However, this study shows mechanical thrombectomy is actually helping rather than hurting these patients.
— Dr. Sean Lavine
LVADs are surgically implanted inside the heart’s failing left ventricle when the heart can no longer effectively pump blood on its own. Originally used as a bridge to heart transplantation, LVADs are increasingly used to assist heart recovery and as destination therapy for end-stage heart failure patients when transplantation is not an option. Although advances in device technology and management protocols have reduced LVAD complications, stroke remains a formidable risk.
At NewYork-Presbyterian/
“Technologies are being developed at a rapid pace that provide us with a number of different tools to treat stroke in new ways,” says Dr. Mandigo, Associate Program Director of Neurological Surgery at NewYork-Presbyterian/
The goal of this study was to see if performing mechanical thrombectomy in LVAD patients who have a stroke is helping them. Our team’s experience with LVAD patients put us in a unique position to study the impact of MT in this high-risk population.
— Dr. Grace Mandigo
“The goal of our study was to see if performing mechanical thrombectomy in LVAD patients who have a stroke is helping them,” she continues. “Our team’s experience with LVAD patients put us in a unique position to study the impact of MT in this high-risk population.”
Grace K. Mandigo, MD
For the study, the physicians conducted a retrospective analysis of a large nationwide sample of all adult patients hospitalized with AIS from 2005 to 2018. They compared outcomes following MT in patients with and without LVAD using regression models in which they adjusted for patient demographics, hospital factors, and clinical severity. The researchers also performed subgroup analyses in LVAD patients experiencing stroke in the post-operative setting and stroke in the setting of pre-existing devices.
Out of 1,633,234 acute ischemic stroke hospitalizations identified:
- 794 occurred in patients with LVADs;
- Roughly 61% were post-operative; and
- Post-stroke in-hospital mortality was higher among patients with LVADs (23.3% vs 7.23%, P < 0.001)
Among those receiving mechanical thrombectomy, mortality was also higher in the LVAD population (31.0% vs 14.1%, P=0.009), though the researchers thought this was largely driven by the post-operative LVAD subgroup. In multivariable analysis, only post-operative LVAD patients experienced greater odds of in-hospital death after MT (adjusted odds ratio (aOR): 8.66, confidence interval (CI):1.46–51.3); patients with pre-existing LVADs demonstrated no difference in post-MT mortality (aOR: 1.06; 95% CI: 0.29–3.91) or in odds of discharge home after MT (aOR 0.63, CI: 0.17–2.32).
Based on these results, the researchers concluded that mechanical thrombectomy is a viable treatment approach in
“Before we began this study, we thought the outcomes may not be as good for LVAD patients because they tend to be sicker than other patients, and we’re playing with anticoagulation, so perhaps they may have worse outcomes,” explains Dr. Mandigo. “Fortunately, we saw that patients with LVADs had the same outcomes as patients without the devices.”
“There was a lot of trepidation among our colleagues that we may be hurting LVAD patients due to issues with anticoagulation,” adds Dr. Lavine. “However, this study shows mechanical thrombectomy is actually helping rather than hurting them. Some interventionalists may be apprehensive to perform a mechanical thrombectomy on a patient with a LVAD device, but this study signals that, even if the patient is complex, the procedure is worth doing. If physicians are concerned about access, we can always find alternative access methods, such as going through the arm or groin.”
The study also highlights the importance of receiving stroke care at a comprehensive stroke center. “Columbia is a very high level LVAD volume center, and we also happen to be a comprehensive stroke center,” says Dr. Mandigo. “For patients with LVADs, this study suggests that receiving this high level of inpatient care at comprehensive stroke center will give patients the best chance for a positive outcome.”
