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  • A Single-Institution Experience with Neurosurgical Complications of Ventricular Assist Device Therapy in Adults

    Final Number:

    Daniel Satoshi Ikeda MD; Darla Talbott NP; Promod Pillai MD MCh; Eric Sauvageau MD; Chittoor B Sai-Sudhakar MBBS; Ciaran J. Powers MD, PhD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    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.

    References: 1. Aggarwal A, Gupta A, Kumar S, et al. Are blood stream infections associated with an increased risk of hemorrhagic stroke in patients with a left ventricular assist device? ASAIO journal. Sep-Oct 2012;58(5):509-513. 2. Butler J, Marti C, Pina I, DeFilippi C. Scope of heart failure hospitalization. Congestive heart failure. Sep-Oct 2012;18 Suppl 1:S1-4. 3. Goldstein DJ, Oz MC, Rose EA. Implantable left ventricular assist devices. The New England journal of medicine. Nov 19 1998;339(21):1522-1533. 4. Haque R, Wojtasiewicz T, Gerrah R, et al. Management of intracranial hemorrhage in a child with a left ventricular assist device. Pediatric transplantation. Aug 2012;16(5):E135-139. 5. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. Mar 1 2011;123(8):933-944. 6. Hemphill JC, 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke; a journal of cerebral circulation. Apr 2001;32(4):891-897. 7. Lazar RM, Shapiro PA, Jaski BE, et al. Neurological events during long-term mechanical circulatory support for heart failure: the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) experience. Circulation. May 25 2004;109(20):2423-2427. 8. Long JW, Healy AH, Rasmusson BY, et al. Improving outcomes with long-term "destination" therapy using left ventricular assist devices. The Journal of thoracic and cardiovascular surgery. Jun 2008;135(6):1353-1360; discussion 1360-1351. 9. Mayer RR, Hwang SW, Reddy GD, et al. Neurosurgical complications of left ventricular assist devices in children. Journal of neurosurgery. Pediatrics. Nov 2012;10(5):370-375. 10. Park SJ, Milano CA, Tatooles AJ, et al. Outcomes in advanced heart failure patients with left ventricular assist devices for destination therapy. Circulation. Heart failure. Mar 1 2012;5(2):241-248. 11. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. The New England journal of medicine. Nov 15 2001;345(20):1435-1443. 12. Spanier T, Oz M, Levin H, et al. Activation of coagulation and fibrinolytic pathways in patients with left ventricular assist devices. The Journal of thoracic and cardiovascular surgery. Oct 1996;112(4):1090-1097.

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