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Clinical Risk Factors and Predictors of Cerebrovascular Accidents in Patients with a Ventricular Assist Device
H. Tsukui, J. J. Teuteberg, S. Winowich, E. Stanford, S. A. Weaver, M. Mathier, D. M. McNamara, L. M. Cadaret, M. A. Simon, R. L. Kormos. University of Pittsburgh Medical Center, Pittsburgh, PA,
BACKGROUND:A cerebrovascular accident (CVA) is a devastating adverse event in a patient (pt) on a ventricular assist device (VAD). The goal was to clarify risk factors of CVA.
METHODS:Prospectively collected VAD implantation data including medical history, VAD type, leukocyte count, thrombelastograph (TEG) and infection was reviewed retrospectively in 124 pts (64 left VAD [LVAD], 60 biventricular VAD [BiVAD]). .
RESULTS:Thirty-one pts (24%) had 48 CVAs. Mean VAD support periods were 228 and 89 days in pts with and without CVA, respectively (p<0.0001). Actuarial freedom from CVA at 6 months was 75%, 64%, 63%, and 33% on HeartMate, Thoratec BiVAD, Thoratec LVAD, and Novacor, respectively (Figure). Twenty CVAs (42%) occurred on pts with infections. Mean leukocyte count at CVA exceeded normal range in pts with infection (12,900 /mm3) and without infection (9,500 /mm3). Mean maximum amplitude of TEG in periods with infection (63.6 mm) was higher than that without infection (60.7 mm) (p=0.0309).
CONCLUSIONS:The risk of CVA increases with longer VAD support periods. The greatest period of risk appears to be in the first 4 months of support. Infection may activate platelet function and predispose to CVA. An elevation of the leukocyte count could also exacerbate the risk of CVA even in pts without infections. Prevention of infection and meticulous control of anticoagulation on pts with infection and/or leukocyte count elevation would be keys to prevent CVA. 
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