Cerebrovascular Events After Continuous-Flow Left Ventricular Assist Devices

  • Pouya Tahsili-Fahadan
  • David R. Curfman
  • Albert A. Davis
  • Noushin Yahyavi-Firouz-Abadi
  • Lucia Rivera-Lara
  • Michael E. Nassif
  • Shane J. LaRue
  • Gregory A. Ewald
  • Allyson R. Zazulia
Original Article



Cerebrovascular events (CVE) are among the most common and serious complications after implantation of continuous-flow left ventricular assist devices (CF-LVAD). We studied the incidence, subtypes, anatomical distribution, and pre- and post-implantation risk factors of CVEs as well as the effect of CVEs on outcomes after CF-LVAD implantation at our institution.


Retrospective analysis of clinical and neuroimaging data of 372 patients with CF-LVAD between May 2005 and December 2013 using standard statistical methods.


CVEs occurred in 71 patients (19%), consisting of 35 ischemic (49%), 26 hemorrhagic (37%), and 10 ischemic+hemorrhagic (14%) events. History of coronary artery disease and female gender was associated with higher odds of ischemic CVE (OR 2.84 and 2.5, respectively), and diabetes mellitus was associated with higher odds of hemorrhagic CVE (OR 3.12). While we found a higher rate of ischemic CVEs in patients not taking any antithrombotic medications, no difference was found between patients with ischemic and hemorrhagic CVEs. Occurrence of CVEs was associated with increased mortality (HR 1.62). Heart transplantation was associated with improved survival (HR 0.02). In patients without heart transplantation, occurrence of CVE was associated with decreased survival.


LVADs are associated with high rates of CVE, increased mortality, and lower rates of heart transplantation. Further investigations to identify the optimal primary and secondary stroke prevention measures in post-LVAD patients are warranted.


Stroke Left ventricular assist device Heart failure Cardiac transplant 


Authors contribution

PT-F, DRC, AAD, and ARZ involved in study concept and design. PT-F, DRC, AAD, LR-L, NY-F-A, and ARZ helped in acquisition, analysis, or interpretation of data. LR-L helped in statistical analysis. PT-F drafted the manuscript. MEN, SJL, Ewald, ARZ contributed to critical revision of the manuscript for important intellectual content. ARZ helped in study supervision.


This study was supported, in part, by research funds from the National Institutes of Health (NIH Grant U10 HL110309, Heart Failure Network) and Grant Number UL1 TR000448 R01 HL097036.

Compliance with Ethical Standards


GAE has received research support from Biocontrol, CareDx, and Medtronic and consulting fees from Abbott. The other authors have no conflict to report.


  1. 1.
    Miller LW, Pagani FD, Russell SD, John R, Boyle AJ, Aaronson KD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med. 2007;357:885–96.CrossRefPubMedGoogle Scholar
  2. 2.
    Eckman PM, John R. Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation. 2012;125:3038–47.CrossRefPubMedGoogle Scholar
  3. 3.
    Kurien S, Hughes KA. Anticoagulation and bleeding in patients with ventricular assist devices: walking the tightrope. AACN Adv Crit Care. 2012;23:91–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009;361:2241–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Kirklin JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, Miller MA, et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. 2013;32:141–56.CrossRefPubMedGoogle Scholar
  6. 6.
    Harvey L, Holley C, Roy SS, Eckman P, Cogswell R, Liao K, et al. Stroke after left ventricular assist device implantation: outcomes in the continuous-flow era. Ann Thorac Surg. 2015;100:535–41.CrossRefPubMedGoogle Scholar
  7. 7.
    Lahpor J, Khaghani A, Hetzer R, Pavie A, Friedrich I, Sander K, et al. European results with a continuous-flow ventricular assist device for advanced heart-failure patients. Eur J Cardiothorac Surg. 2010;37:357–61.PubMedGoogle Scholar
  8. 8.
    Morgan JA, Brewer RJ, Nemeh HW, Gerlach B, Lanfear DE, Williams CT, et al. Stroke while on long-term left ventricular assist device support: incidence, outcome, and predictors. ASAIO J. 2014;60:284–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Nakajima I, Kato TS, Komamura K, Takahashi A, Oda N, Sasaoka T, et al. Pre- and post-operative risk factors associated with cerebrovascular accidents in patients supported by left ventricular assist device. -Single center’s experience in japan-. Circ J. 2011;75:1138–46.CrossRefPubMedGoogle Scholar
  10. 10.
    Nassif ME, Tibrewala A, Raymer DS, Andruska A, Novak E, Vader JM, et al. Systolic blood pressure on discharge after left ventricular assist device insertion is associated with subsequent stroke. J Heart Lung Transplant. 2015;34:503–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Kato TS, Schulze PC, Yang J, Chan E, Shahzad K, Takayama H, et al. Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant. 2012;31:1–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Trachtenberg BH, Cordero-Reyes AM, Aldeiri M, Alvarez P, Bhimaraj A, Ashrith G, et al. Persistent blood stream infection in patients supported with a continuous-flow left ventricular assist device is associated with an increased risk of cerebrovascular accidents. J Card Fail. 2015;21:119–25.CrossRefPubMedGoogle Scholar
  13. 13.
    Stulak JM, Lee D, Haft JW, Romano MA, Cowger JA, Park SJ, et al. Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant. 2014;33:60–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Backesa D, van den Bergha WM, van Duijna AL, Lahporb J, van Dijka D, Slootera A. Cerebrovascular complications of left ventricular assist devices. Eur J Cardiothorac Surg. 2012;42:612–20.CrossRefGoogle Scholar
  15. 15.
    Sakaguchi M, Kitagawa K, Okazaki S, Yoshioka D, Sakata Y, Mochizuki H, et al. Sulcus subarachnoid hemorrhage is a common stroke subtype in patients with implanted left ventricular assist devices. Eur J Neurol. 2015;22:1088–93.CrossRefPubMedGoogle Scholar
  16. 16.
    Baumann Kreuziger LM, Kim B, Wieselthaler GM. Antithrombotic therapy for left ventricular assist devices in adults: a systematic review. J Thromb Haemost. 2015;13:946–55.CrossRefPubMedGoogle Scholar
  17. 17.
    Menon AK, Götzenich A, Sassmannshausen H, Haushofer M, Autschbach R, Spillner JW. Low stroke rate and few thrombo-embolic events after HeartMate II implantation under mild anticoagulation. Eur J Cardiothorac Surg. 2012;42:319–23.CrossRefPubMedGoogle Scholar
  18. 18.
    Litzler PY, Smail H, Barbay V, Nafeh-Bizet C, Bouchart F, Baste JM, et al. Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience. Eur J Cardiothorac Surg. 2014;45:55–9.CrossRefPubMedGoogle Scholar
  19. 19.
    van den Bergh WM, Lansink-Hartgring AO, van Duijn AL, Engström AE, Lahpor JR, Slooter AJ. Thromboembolic stroke in patients with a HeartMate-II left ventricular assist device—the role of anticoagulation. J Cardiothorac Surg. 2015;10:128.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Baumann Kreuziger LM. Management of anticoagulation and antiplatelet therapy in patients with left ventricular assist devices. J Thromb Thrombolysis. 2015;39:337–44.CrossRefPubMedGoogle Scholar
  21. 21.
    Nassif ME, LaRue SJ, Raymer DS, Novak E, Vader JM, Ewald GA, et al. Relationship between anticoagulation intensity and thrombotic or bleeding outcomes among outpatients with continuous-flow left ventricular assist devices. Circ Heart Fail. 2016;9:e002680.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Katz JN, Adamson RM, John R, Tatooles A, Sundareswaran K, Kallel F, et al. Safety of reduced anti-thrombotic strategies in HeartMate II patients: a one-year analysis of the US-TRACE study. J Heart Lung Transplant. 2015;34:1542–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Crow S, Chen D, Milano C, Thomas W, Joyce L, Piacentino V 3rd, et al. Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg. 2010;90:1263–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Heilmann C, Geisen U, Beyersdorf F, Nakamura L, Benk C, Berchtold-Herz M, et al. Acquired von Willebrand syndrome in patients with ventricular assist device or total artificial heart. Thromb Haemost. 2010;103:962–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Geisen U, Heilmann C, Beyersdorf F, Benk C, Berchtold-Herz M, Schlensak C, et al. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease. Eur J Cardiothorac Surg. 2008;33:679–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Uriel N, Pak SW, Jorde UP, Jude B, Susen S, Vincentelli A, et al. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol. 2010;56:1207–13.CrossRefPubMedGoogle Scholar
  27. 27.
    Klovaite J, Gustafsson F, Mortensen SA, Sander K, Nielsen LB. Severely impaired von Willebrand factor-dependent platelet aggregation in patients with a continuous-flow left ventricular assist device (HeartMate II). J Am Coll Cardiol. 2009;53:2162–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Pouya Tahsili-Fahadan
    • 1
    • 2
  • David R. Curfman
    • 3
  • Albert A. Davis
    • 3
  • Noushin Yahyavi-Firouz-Abadi
    • 4
  • Lucia Rivera-Lara
    • 1
    • 5
  • Michael E. Nassif
    • 6
  • Shane J. LaRue
    • 6
  • Gregory A. Ewald
    • 6
  • Allyson R. Zazulia
    • 3
    • 7
  1. 1.Department of NeurologyJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of MedicineVirginia Commonwealth UniversityFalls ChurchUSA
  3. 3.Department of NeurologyWashington University School of MedicineSt. LouisUSA
  4. 4.Department of Radiology and Radiological SciencesJohns Hopkins University School of MedicineBaltimoreUSA
  5. 5.Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  6. 6.Department of Medicine, Cardiovascular DivisionWashington University School of MedicineSt. LouisUSA
  7. 7.Department of RadiologyWashington University School of MedicineSt. LouisUSA

Personalised recommendations