Stroke outcomes following durable left ventricular assist device implant in patients bridged with micro-axial flow pump: Insights from a large registry.
bridge strategy
impella
left ventricular assist device
micro‐axial flow pump
outcomes
stroke
Journal
Artificial organs
ISSN: 1525-1594
Titre abrégé: Artif Organs
Pays: United States
ID NLM: 7802778
Informations de publication
Date de publication:
27 May 2024
27 May 2024
Historique:
revised:
09
04
2024
received:
08
01
2024
accepted:
09
05
2024
medline:
28
5
2024
pubmed:
28
5
2024
entrez:
28
5
2024
Statut:
aheadofprint
Résumé
Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled. Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied. Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality. Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.
Sections du résumé
BACKGROUND
BACKGROUND
Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled.
METHODS
METHODS
Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied.
RESULTS
RESULTS
Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality.
CONCLUSIONS
CONCLUSIONS
Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.
Références
Yuzefpolskaya M, Schroeder SE, Houston BA, Robinson MR, Gosev I, Reyentovich A, et al. The Society of Thoracic Surgeons Intermacs 2022 annual report: focus on the 2018 Heart Transplant Allocation System The 13th annual report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Cir. Ann Thorac Surg. 2023;115:311–339.
Tedford RJ, Leacche M, Lorts A, Drakos SG, Pagani FD, Cowger J. Durable mechanical circulatory support: JACC scientific statement. J Am Coll Cardiol. 2023;82:1464–1481.
Teuteberg JJ, Cleveland JC, Cowger J, Higgins RS, Goldstein DJ, Keebler M, et al. The Society of Thoracic Surgeons Intermacs 2019 annual report: the changing landscape of devices and indications. Ann Thorac Surg. 2020 Mar 1;109(3):649–660.
Hernandez‐Montfort JA, Xie R, Ton VK, Meyns B, Nakatani T, Yanase M, et al. Longitudinal impact of temporary mechanical circulatory support on durable ventricular assist device outcomes: an IMACS registry propensity matched analysis. J Heart Lung Transplant. 2020 Feb 1;39(2):145–156.
Akin S, Soliman O, de By TMMH, Muslem R, Tijssen JGP, Schoenrath F, et al. Causes and predictors of early mortality in patients treated with left ventricular assist device implantation in the European registry of mechanical circulatory support (EUROMACS). Intensive Care Med. 2020 Jul 1;46(7):1349–1360.
Vallabhajosyula S, Arora S, Lahewala S, Kumar V, Shantha GPS, Jentzer JC, et al. Temporary mechanical circulatory support for refractory cardiogenic shock before left ventricular assist device surgery. J Am Heart Assoc. 2018 Nov 1;7(22):e010193.
Bertoldi LF, Pappalardo F, Lubos E, Grahn H, Rybczinski M, Barten MJ, et al. Bridging INTERMACS 1 patients from VA‐ECMO to LVAD via Impella 5.0: de‐escalate and ambulate. J Crit Care. 2020 Jun 1;57:259–263.
Bernhardt AM, Zipfel S, Reiter B, Hakmi S, Castro L, Söffker G, et al. Impella 5.0 therapy as a bridge‐to‐decision option for patients on extracorporeal life support with unclear neurological outcomes. Eur J Cardiothorac Surg. 2019 Dec 1;56(6):1031–1036.
Cheng R, Tank R, Ramzy D, Azarbal B, Chung J, Esmailian F, et al. Clinical outcomes of Impella microaxial devices used to salvage cardiogenic shock as a bridge to durable circulatory support or cardiac transplantation. ASAIO J. 2019 Sep 1;65(7):642–648.
Willey JZ, Gavalas MV, Trinh PN, Yuzefpolskaya M, Reshad Garan A, Levin AP, et al. Outcomes after stroke complicating left ventricular assist device. J Heart Lung Transplant. 2016 Aug 1;35(8):1003–1009.
Cowger JA, Shah P, Pagani FD, Grafton G, Stulak J, Chamogeorgakis T, et al. Outcomes based on blood pressure in patients on continuous flow left ventricular assist device support: an interagency registry for mechanically assisted circulatory support analysis. J Heart Lung Transplant. 2020 May 1;39(5):441–453.
Shah P, Birk SE, Cooper LB, Psotka MA, Kirklin JK, Barnett SD, et al. Stroke and death risk in ventricular assist device patients varies by ISHLT infection category: an INTERMACS analysis. J Heart Lung Transplant. 2019 Jul 1;38(7):721–730.
Amin AP, Spertus JA, Curtis JP, Desai N, Masoudi FA, Bach RG, et al. The evolving landscape of Impella use in the United States among patients undergoing percutaneous coronary intervention with mechanical circulatory support. Circulation. 2020;141:273–284.
Kormos RL, Antonides CFJ, Goldstein DJ, Cowger JA, Starling RC, Kirklin JK, et al. Updated definitions of adverse events for trials and registries of mechanical circulatory support: a consensus statement of the mechanical circulatory support academic research consortium. J Heart Lung Transplant. 2020;39:735–750.
Vandenbriele C, Arachchillage DJ, Frederiks P, Giustino G, Gorog DA, Gramegna M, et al. Anticoagulation for percutaneous ventricular assist device‐supported cardiogenic shock: JACC review topic of the week. J Am Coll Cardiol. 2022;79:1949–1962.
Saeed D, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, et al. Stroke complications in patients requiring durable mechanical circulatory support systems after extracorporeal life support. ASAIO J. 2023 Feb 1;69(2):145–150.
Esposito ML, Morine KJ, Annamalai SK, O'Kelly R, Aghili N, Pedicini R, et al. Increased plasma‐free hemoglobin levels identify hemolysis in patients with cardiogenic shock and a trans valvular micro‐axial flow pump. Artif Organs. 2019 Feb 1;43(2):125–131.
Jurmann MJ, Siniawski H, Erb M, Drews T, Hetzer R. Initial experience with miniature axial flow ventricular assist devices for postcardiotomy heart failure. Ann Thorac Surg. 2004 May;77(5):1642–1647.
Van Edom CJ, Gramegna M, Baldetti L, Beneduce A, Castelein T, Dauwe D, et al. Management of bleeding and hemolysis during percutaneous microaxial flow pump support: a practical approach. JACC Cardiovasc Interv. 2023;16:1707–1720.
Roberts N, Chandrasekaran U, Das S, Qi Z, Corbett S. Hemolysis associated with Impella heart pump positioning: in vitro hemolysis testing and computational fluid dynamics modeling. Int J Artif Organs. 2020 Nov 1;43(11):710–718.
Baldetti L, Beneduce A, Romagnolo D, Frias A, Gramegna M, Sacchi S, et al. Impella malrotation within the left ventricle is associated with adverse in‐hospital outcomes in cardiogenic shock. JACC Cardiovasc Interv. 2023;16:739–741.
Baldetti L, Nardelli P, Ajello S, Melisurgo G, Calabrò MG, Pieri M, et al. Anti‐thrombotic therapy with cangrelor and bivalirudin in venoarterial extracorporeal membrane oxygenation patients undergoing percutaneous coronary intervention: a single‐center experience. ASAIO J. 2023 Jul 1;69(7):E346–E350.
Colombo PC, Mehra MR, Goldstein DJ, Estep JD, Salerno C, Jorde UP, et al. Comprehensive analysis of stroke in the long‐term cohort of the MOMENTUM 3 study: a randomized controlled trial of the HeartMate 3 versus the HeartMate II cardiac pump. Circulation. 2019 Jan 8;139(2):155–168.
Acharya D, Loyaga‐Rendon R, Morgan CJ, Sands KA, Pamboukian SV, Rajapreyar I, et al. INTERMACS analysis of stroke during support with continuous‐flow left ventricular assist devices risk factors and outcomes. JACC Heart Fail. 2017;5(10):703–711.