A 32 years old socially and physically active female with no previously
known comorbidities has presented to tertiary hospital with shortness of
breath at rest, progressive weakness and dry cough.
On admission, she was conscious and alert, pale with
cool clammy peripheries. Her respiratory rate was 26 breaths per minute.
Electrocardiogram revealed sinus rhythm with rate of 100 beats per minute.
According to the patient, she had no diuresis for the past 12 hours. A
patient underwent urgent transthoracic echocardiogram. It revealed
severely impaired and enlarged left ventricle. Patient was admitted to
hospital, a diagnosis of dilated cardiomyopathy resulting severe heart failure
(NYHA class IV) was made.
She received an optimal medical treatment with loop
and potassium sparing diuretics, angiotensinconverting-enzyme inhibitor and р-Receptor blockers. Despite that management her clinical
symptoms deteriorated rapidly and the patient was transferred to intensive
therapy unit were intravenous p1-agonist (Dobutamine) was initiated. A
given treatment has not improved patient's clinical status and she
was sliding into INTERMACS class II . It allowed clinicians to put the
patient on the heart transplant-awaiting list.
Patients clinical symptoms continued to deteriorate
rapidly and fully magnetically levitated centrifugal-flow pump was implanted
(HeartMate 3, Abbott). The operation was performed in the routine manner,
through median sternotomy, on beating heart and completed without any incident
or complications. After procedure the patient transferred to the intensive
care unit with mild inotrope doses.
After 4 hours sedation was discontinued and weakness
of the left upper and lower limbs was noticed. Computed tomography (CT)
perfusion and CT scan angiography were performed, revealing right middle
cerebral artery (M1) thrombosis (ASPECTS 10) and wide penumbra with no
ischemic core zone (fig. 1 and 2).
Fig. 1. Computed tomography of cerebral perfusion
showing wide penumbra with no ischemic core zone on the right cerebral hemisphere
Fig. 2. Computed tomography scan angiography
revealing occlusion of the right middle cerebral artery (M1) (arrow) and no
blood flow to distal arteries (circle)
Mechanical thrombus extraction was performed in the
catheterization laboratory by the interventional radiologist using 6x25 mm
stent retriever restoring blood flow to the right middle cerebral
artery (Thrombolysis in Cerebral Infarction [TICI] score = 3) (fig. 3
Fig. 3. Thrombosis in the right middle cerebral artery (M1)
Fig. 4. Completely restored blood flow to the right middle
cerebral artery (TICI score 3) with Trevo XP Stentriever 6×25 mm
Patient limb strength fully recovered within two days
with no residual symptoms. Further down the clinical course of the patient
was relatively uneventful and she was discharged to
rehabilitation facility on the 20th postoperative day. 21
months after LVAD implantation the patient is well, she returned to her normal
social and physical activities. She continues to attend scheduled
outpatient visits; no other cerebrovascular episodes occurred or
Cerebral thromboembolic complications in LVAD
patients, despite reduced incidents of stroke with the newest generation
devices, remain a difficult challenge, keeping patients with no disability.
Even with the latest fully magnetically levitated technology ischemic
stroke incidence may reach 6.5% . Regarding long-term, LVAD patients in time
have a risk of developing ischemic stroke, as a result of atrial
fibrillation, pump thrombosis, systemic infection, inadequate antithrombotic
treatment . Although these risk factors increase chances of ischemic
cerebrovascular events in the long-term after LVAD implantation, in the first
days after the procedure theoretically they are less likely to take place.
In our case, the patient had none of the risk factors mentioned
above, LVAD implantation performed without any
procedural complications, exact onset of the stroke symptoms was
unknown, and it leaves only to speculate on the cerebral thrombosis
The treatment options for ischemic stroke include
intravenous thrombolytic therapy with intravenous recombinant tissue
plasminogen activator (rtPA), intra-arterial thrombolysis in patients
major stroke onset less than 6 hours' due to occlusions of the MCA
and who is not otherwise candidates for intravenous rtPA, and mechanical
thrombus extraction [4, 5].
In our case thrombolysis was contraindicated since the
operation was executed on the same day, which could lead to major bleeding. Regardless of the
unexplained etiology and unclear thromboembolic event time, to avoid
unfavorable neurological sequel immediate treatment had to be performed.
Mechanical thrombus removal was the most suitable choice for immediate
restoration of the blood flow to an occluded cerebral artery decreasing
chances of irreversible changes in brain tissue.
progress of LVAD's in reducing the risk of stroke, cerebral thromboembolic
events remain an undesirable possibility and often are disabling
and/ or life threatening. Early stroke incident after LVAD implantation
eliminates the method of thrombolytic therapy, as could lead to major
bleeding. Urgent mechanical thrombus extraction is encouraged,
having favorable results in symptoms-free recovery.
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Patel P.C., et al. IN-TERMACS (Interagency Registry for Mechanically
Assisted Circulatory Support) Profiling Identifies Ambulatory
Patients at High Risk on Medical Therapy After Hospitalizations
for Heart Failure. Circ Heart Fail. 2016; 9 (11). DOI: https://doi.org/10.1161/CIRCHEARTFAILURE.116.003032
2. Colombo P.C., Mehra M.R.,
Goldstein D.J., 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; 139 (2):
155-68. DOI: https:// doi.org/10.1161/CIRCULATIONAHA.118.037231
3. Cho S.M., Hassett C., Rice C.J.,
Starling R., Kat-zan I., Uchino K. What Causes LVAD-Associated Ischemic Stroke? Surgery,
Pump Thrombosis, Antithrombotics, and Infection. ASAIO J. 2019; 65 (8): 775-80.
4. Adams H.P., del Zoppo G., Alberts
M.J., et al. Guidelines for the Early Management of Adults With Ischemic
Stroke. Stroke. Published
online 2007. DOI: https://doi.org/10.1161/strokeaha.107.181486
5. Powers W.J., Rabinstein A.A.,
Ackerson T., et al. 2018 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke: A Guideline for
Healthcare Professionals From the American Heart Association/ American
Stroke Association. Stroke. Published online 2018. DOI: https://doi.org/10.1161/STR.0000000000000158