SEATTLE — Perhaps the biggest downside of left ventricular assist devices (LVADs) for people with end-stage heart failure is the substantial risk of stroke they carry. But a new study indicates that patients can still undergo a successful heart transplant after an LVAD-related stroke.
Among stroke patients after receiving LVADs as bridging therapy to transplant at a major referral center and then proceeding to transplant, mid- and long-term outcomes were just as good as for recipients of LVAD without stroke, reported Aaron Shoskes, DO, of the Cleveland Clinic in Ohio.
Speaking at the annual meeting of the American Academy of Neurology here, Shoskes noted that most stroke patients never received the hoped-for transplant. Nonetheless, he said, “some patients” considered transplantable after stroke “can safely proceed to transplant” without diminishing expectations of success.
LVADs are implanted devices that increase the pumping action of the failing heart. They have become invaluable in recent years in keeping heart failure patients alive while they wait for a suitable donor heart for transplant. (LVADs are also approved as so-called destination therapy, that is, as a semi-permanent solution for transplant-unsuitable patients.) Unfortunately, as Shoskes observed, strokes are common in LVAD recipients, with rates of approximately 10% per patient. -year.
The risk comes from multiple directions, Shoskes explained. Implantation surgery is an obvious source; but also, subtle changes in blood flow can trigger thrombosis, and the blood-thinning medications that patients must take because of these risks make them vulnerable to cerebral hemorrhages.
Clearly, a stroke from any source is debilitating and it is no surprise that patients already weakened by heart failure can become too weak for the rigors of transplantation. But that doesn’t have to be the case for everyone, and Shoskes’ group thought it would be helpful to look at the factors associated with favorable outcomes.
At the Cleveland Clinic, patients receiving LVADs are prospectively enrolled in a registry. Shoskes and his colleagues collected records of those receiving them as bridging therapy from 2004, excluding children and those who only kept the devices on for short periods. Of the 479 who met these criteria, 81 had a stroke while waiting for a transplant.
Only 25 of those 81 ended up getting donor hearts. However, none of these patients died within the first year after transplantation, compared to 8% of the 219 stroke-free LVAD recipients. Two-year post-transplant mortality was also lower for people who had strokes on LVAD (5% versus 10%), and post-transplant stroke rates were virtually identical. (Furthermore, while most stroke patients did not undergo a transplant, having no stroke did not guarantee transplant success – approximately 45% of the stroke-free group n had not received a donor heart at the time of the data lock.)
In the stroke group, factors related to better outcomes included less stroke severity and an ischemic event versus a hemorrhagic event.
Limitations of the study included the small number of LVAD stroke patients who subsequently underwent transplantation and the restriction to a single center.
Shoskes reported no personal financial interests, but an immediate family member had working relationships with Exact Sciences and Fulcrum Therapeutics. Some co-authors also had relationships with commercial entities.