Introduction: Ventricular assist devices (VADs) are utilized more frequently in the management of patients with advanced heart failure due to benefits in survival and quality of life. Neurological injuries are a significant source of morbidity and mortality in these patients. However, there is scarce literature on the neurosurgical complications (NCs) these patients suffer. The aim of this investigation was to describe the prognostic variables in VAD patients who suffer NCs and the outcomes after neurosurgical intervention.
Methods: In this single-institution review, the records of 159 consecutive patients who underwent VAD implantation from January 2007 to December 2011 were retrospectively analyzed. Patients with VADs who suffered permanent neurological injuries were identified. NCs were defined as neurological injuries that the neurosurgical service evaluated or intervened on. Premorbid stroke, sex, presenting Glasgow Coma Scale (GCS) score (15 vs <15), time from VAD implant (±one year), and ±neurosurgical intervention were evaluated as categorical variables by Chi-squared analysis to predict 30-day mortality. Student’s t-test was used to evaluate continuous variables, presenting international normalized ratio (INR) and age.
Results: Nineteen VAD patients suffered NCs during the study period. Eight patients underwent neurosurgical procedures (6 cranial, 2 endovascular). The 30-day mortality of NCs overall and for those undergoing neurosurgical interventions was 63.2% and 87.5%, respectively. A presenting GCS of <15 (P=0.0095) and VAD implantation time >1 year (P=0.0031) were associated with increased mortality. Although there was increased mortality in patients that underwent neurosurgical procedures (87.5%) when compared to patients managed conservatively (45.4%), this was not statistically significant (P=0.0607).
Conclusions: Patients who undergo VAD therapy are at significant risk for suffering a NC. Our single-institution experience demonstrated an exceedingly high mortality rate, regardless of therapy. Lower GCS and length of time from VAD implantation negatively impact 30 day survival. This information may be useful to guide the management of this patient population.
Patient Care: Patients with ventricular assist devices that suffer neurological injuries have an extremely poor prognosis. Although intuitive, this review demonstrates that aggressive surgical management of this cohort is met with high mortality. In this age of scrutiny regarding medical resource utilization, it is important to know which patients will benefit from aggressive surgical measures. Hopefully, this research will educate physicians about this unfortunate patient population and motivate them to identify VAD patients that would benefit from a neurosurgical intervention.
Learning Objectives: By the conclusion of this session, participants should: 1) be able to recognize that patients with VADs and neurosurgical injuries suffer high morbidity and mortality, 2) understand that emergent, ‘heroic’ procedures on these patients are often met with little to no improvement in neurological exam, 3) discuss their own experiences, and 4) help define treatment strategies to improve the outcomes in this cohort.
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