Understanding risk factors and predictors for stroke subtypes in the ENDURANCE trials. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Cho, S., Starling, R. C., Teuteberg, J., Rogers, J., Pagani, F., Shah, P., Uchino, K., Hiivala, N. 2020


BACKGROUND: Stroke is a devastating morbidity associated with left ventricular assist device (LVAD) support. We report a comprehensive analysis of stroke subtypes in the ENDURANCE destination therapy (DT) and ENDURANCE Supplemental (DT2) trials.METHODS: Patients in the combined HeartWare LVAD (HVAD) cohorts of the DT and DT2 trials were included. Neurologic events included ischemic stroke (ischemic cerebrovascular accident [ICVA]), hemorrhagic stroke (hemorrhagic cerebrovascular accident [HCVA]), and transient ischemic attack (TIA). Peri-operative strokes were defined as occurring within 2 weeks of the implant.RESULTS: A total of 604 patients received an HVAD in the DT (n?=?296) and DT2 (n?=?308) trials. Over 2 years, 178 (29.5%) had at least 1 cerebrovascular accident (CVA). Forty-four (7.3%) had HCVAs, 116 (19.2%) had ICVAs, and 44 (7.3%) had TIAs. Thirty (5.0%) had peri-operative stroke. In multivariable analysis, sub-therapeutic international normalized ratio (INR) values were independently associated with peri-operative stroke. Supra- and/or sub-therapeutic INR values, peripheral vascular disease, and presence of left ventricular thrombus were independently associated with ICVA. No aspirin and supra- and/or sub-therapeutic INR values were independently associated with TIA. No aspirin, supra- and/or sub-therapeutic INR values, and prior stroke and/or TIA were associated with HCVA. In further analysis, mean arterial pressure (MAP) was higher in the ICVA (86.8mmHg, p?=?0.0024) and TIA (88.8mmHg, p<0.0001) groups, but not in HCVA, than in the No-CVA group (81.4mmHg). Time in therapeutic range for INR was 65.3% for the No-CVA group, 62.9% (p?=?0.59) for HCVA, 65.1% (p?=?0.97) for ICVA, and 63.2% (p?=?0.62) for TIA.CONCLUSIONS: Supra- and sub-therapeutic INR values at the time of CVA were associated with all stroke subtypes >14 days post-implant. MAP was higher among those with ICVA and TIA but not with HCVA compared to without CVA. Our study demonstrates the challenges of anti-thrombotic therapy and blood pressure management in LVAD population.

View details for DOI 10.1016/j.healun.2020.01.1330

View details for PubMedID 32044205