Клинический случай раннего ишемического инсульта после установки вспомогательного левожелудочкового устройства (LVAD), успешно пролеченного с помощью механической экстракции тромба

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Актуальность. Левожелудочковые вспомогательные устройства (LVAD) все чаще используются у пациентов с прогрессирующей сердечной недостаточностью (СН) для увеличения продолжительности и улучшения качества жизни. Однако даже при использовании центробежных помп последнего поколения с полностью магнитной левитацией защита пациента от церебральных тромбоэмболических осложнений, ассоциирующихся с инвалидизацией, по-прежнему остается сложной задачей. В позднем послеоперационном периоде пациенты, перенесшие установку LVAD, могут получать тромболитические препараты, в то время как в раннем послеоперационном периоде после установки LVAD эти препараты противопоказаны. В настоящей статье представлен клинический случай острого ишемического инсульта, развившегося через несколько часов после установки LVAD. Пациент был успешно пролечен с помощью механической экстракции тромба.

Цель - привлечь внимания хирургов и реаниматологов к ишемическим цереброваскулярным осложнениям в раннем послеоперационном периоде после установки LVAD. Кроме того, представлен эффективный подход, своевременное применение которого позволяет не допустить отдаленной неврологической инвалидизации.

Ключевые слова:сердечная недостаточность, левожелудочковое вспомогательное устройство (LVAD), ишемический инсульт

Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов в отношении настоящей публикации.
Для цитирования: Зоринас А., Янушаускас В., Гайжаускас Э., Гайжаускиене К., Урбонас К., Самалавичус Р.С., Ручинскас К. Клинический случай раннего ишемического инсульта после установки вспомогательного левожелудочкового устройства (LVAD), успешно пролеченного с помощью механической экстракции тромба // Клиническая и экспериментальная хирургия. Журнал имени академика Б.В. Петровского. 2020. Т. 8, № 3. С. 119-122. DOI: https://doi.org/10.33029/2308-1198-2020-8-3-119-122 (англ.)

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 [1]. 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 and 4).

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 were documented.

Discussion

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% [2]. 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 [3]. 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 etiology.

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.

Conclusion

Despite the 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.

References

1.    Stewart G.C., Kittleson M.M., 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. DOI: https://doi.org/10.1097/MAT.0000000000000901

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