木瓜直播

SEATTLE -- Perhaps the biggest downside of left ventricular assist devices (LVADs) for people with end-stage heart failure is the substantial risk of strokes they bring. But a new study indicates that patients can still proceed to successful heart transplant after an LVAD-related stroke.

Among patients suffering strokes after receiving LVADs as bridge-to-transplant therapy at one major referral center, and then proceeding to transplant, medium- and long-term outcomes were just as good as for stroke-free LVAD recipients, reported Aaron Shoskes, DO, of the Cleveland Clinic in Ohio.

Speaking at the American Academy of Neurology's annual meeting here, Shoskes noted that most of the patients who had strokes never did receive the hoped-for transplant. Nevertheless, he said, "select patients" considered transplantable after stroke "can safely go on to transplant" without diminished expectations for success.

LVADs are implanted devices that augment the failing heart's pumping action. They have become invaluable in recent years for keeping heart failure patients alive while they wait for a suitable donor heart for transplant. (LVADs are also approved as so-called destination therapy, i.e., as a semi-permanent fix for patients unsuited for transplant.) Unfortunately, as Shoskes observed, strokes are common in LVAD recipients, with rates in the neighborhood of 10% per patient-year.

The risk comes from several directions, Shoskes explained. The implantation surgery is one obvious source; but also, subtle changes in blood circulation may trigger thrombosis, and the anticoagulant medications that patients must take because of these risks leave patients vulnerable to brain bleeds.

Clearly, stroke from any source is debilitating and it's no surprise that patients already weakened from heart failure may become too weak for the rigors of transplantation. But that need not be the case for all, and Shoskes's group thought it would be worthwhile to examine factors associated with favorable outcomes.

At the Cleveland Clinic, patients receiving LVADs are entered prospectively into a registry. Shoskes and colleagues culled records for those getting them as bridge therapy beginning in 2004, excluding children and those keeping the devices only for short periods. Of the 479 meeting those criteria, 81 experienced strokes while waiting for transplant.

Only 25 of those 81 ended up getting donor hearts. However, none of those patients died in the first year after transplant, versus 8% of the 219 stroke-free LVAD recipients. Two-year post-transplant mortality was also lower for those experiencing strokes on LVADs (5% vs 10%), and stroke rates after transplant were virtually identical. (Also, while most the stroke patients did not proceed to transplant, not having a stroke didn't guarantee successful transplant -- some 45% of the no-stroke group had not received a donor heart as of data lock.)

In the stroke group, factors linked with better outcomes included lower stroke severity and an ischemic versus hemorrhagic event.

Limitations to the study included the small number of LVAD-stroke patients who went on to transplant, and the restriction to a single center.

Comment