Stroke Risk Following Infection in Patients with Continuous-Flow Left Ventricular Assist Device
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ORIGINAL ARTICLE
Stroke Risk Following Infection in Patients with Continuous‑Flow Left Ventricular Assist Device Sung‑Min Cho1,2, Nader Moazami3,4, Stuart Katz5, Adarsh Bhimraj6, Nabin K. Shrestha6 and Jennifer A. Frontera2,7,8* © 2019 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Abstract Background: Infection has been associated with stroke in patients with left ventricular assist devices (LVAD); how‑ ever, little data exist on the timing, type and mortality impact of infection-related stroke. Methods: Prospectively collected data of HeartMate II (N = 332) and HeartWare (N = 70) LVAD patients from a single center were reviewed. Only strokes (ischemic or hemorrhagic) that occurred within 6 weeks following a LVAD infec‑ tion were considered in analyses. The association between LVAD infections (wound, pump pocket, driveline and/or bloodstream infection [BSI]), specific pathogens and ischemic and hemorrhagic strokes was evaluated using multi‑ variable logistic regression analysis. The impact of infection-related stroke on cumulative survival was assessed using Kaplan–Meier analysis. Results: Of 402 patients, LVAD infection occurred in 158 (39%) including BSI in 107 (27%), driveline infection in 67 (17%), wound infection in 31 (8%) and pump pocket infection in 24 (6%). LVAD infection-related stroke occurred in 20/158 (13%) patients in a median of 4 days (0–36 days) from documented infection. In multivariable analysis, ischemic stroke was associated with wound infection (aOR 9.0, 95% CI 2.4–34.0, P = 0.001) and BSI (aOR 7.7, 95% CI 0.9–66.0, P = 0.064), and hemorrhagic stroke was associated with BSI in 100% of cases (P = 0.01). There was no asso‑ ciation with driveline or pump pocket infection. The cumulative survival rate among patients with infection-related stroke was significantly lower compared to those with LVAD infection but no stroke (log-rank P 18) with placement of continuous-flow pump (HeartMate II or HeartWare LVAD) for either bridge to transplant or destination therapy. Infection-related strokes were defined as ischemic or hemorrhagic strokes (subarachnoid hemorrhage [SAH], intraparenchymal hemorrhage or intraventricular hemorrhage [IVH] not due to trauma) occurring within 6 weeks following a documented infection. This time frame was selected to maximize the likelihood that the stroke event was pathophysiologically related to the LVAD infection and because the existing literature suggests the highest risk of stroke occurs in the first month following infective endocarditis [14]. Patients with a LVAD infection and a stroke outside of the prescribed time window (e.g., either before or > 6 weeks after documented LVAD infection) were coded as not having a LVAD infection-related stroke. Exclusion criteria were as follows: placement of a biventricular assist device, total artificial heart or temporary/shortterm mechanical assist circulatory device, traumatic intracranial hemorrhage (including subdural hematoma, traumatic SAH or brain contusion), and lack of
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