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Grace Y. Lai, Paul J. Devlin, Kartik Kesavabhotla, Jonathan D. Rich, Duc T. Pham, Matthew B. Potts, and Babak S. Jahromi

OBJECTIVE

As the use of left ventricular assist devices (LVADs) has expanded, cerebrovascular complications have become an increasing source of morbidity and mortality in this population. Intracranial hemorrhage (ICH) in particular remains a devastating complication in patients who undergo LVAD placement with no defined management guidelines. The authors therefore reviewed surgical and anticoagulation management and outcomes of patients with LVADs who presented to their institution with ICH.

METHODS

This retrospective cohort study assessed outcomes of patients who underwent LVAD placement at a single institution between 2007 and 2016 and in whom imaging demonstrated ICH.

RESULTS

During the study period, 281 patients had a HeartMate II or HeartWare LVAD placed. There were 37 episodes of ICH (recurrent in 3 cases). ICHs were categorized as intraparenchymal hemorrhage (IPH; n = 22, 59%), subdural hemorrhage (SDH; n = 6, 16%), and subarachnoid hemorrhage (SAH; n = 9, 24%). Neurosurgical intervention was deemed necessary in 27.3%, 66.7%, and 0% of patients with IPH, SDH, and SAH, respectively; overall survival > 30 days for each type of hemorrhage was 41%, 83%, and 89%, respectively. No patients had LVAD thrombus as a result of reversal of anticoagulation. Combined with prior reports, good outcomes are seen more often following surgery for SDH than for IPH (57% vs 7%, p = 0.004) in patients who underwent VAD placement.

CONCLUSIONS

Patients with IPH who undergo LVAD placement have poor outcomes regardless of anticoagulation reversal or neurosurgical intervention, whereas those with SDH may have good outcomes with medical and surgical intervention, and those with SAH appear to do well without anticoagulation reversal or surgery. When needed, anticoagulation reversal was not associated with an increase in LVAD thrombosis in this series.

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Grace Y. Lai, William Chu Kwan, Karolina Piorkowska, Matthias W. Wagner, Pouya Jamshidi, Birgit Ertl-Wagner, Thomas Looi, Adam C. Waspe, and James M. Drake

OBJECTIVE

While intraventricular hemorrhage (IVH) is associated with posthemorrhagic ventricular dilation (PHVD), not all infants affected by high-grade IVH develop PHVD. The authors aimed to determine clot-associated predictors of PHVD in a porcine model by varying the amount and rate of direct intraventricular injection of whole autologous blood.

METHODS

Seven 1-week-old piglets underwent craniectomy and injection of autologous blood into the right lateral ventricle. They survived for a maximum of 28 days. MRI was performed prior to injection, immediately postoperatively, and every 7 days thereafter. T1-weighted, T2-weighted, and susceptibility-weighted imaging (SWI) sequences were used to segment ventricular and clot volumes. Spearman correlations were used to determine the relationship between blood and clot volumes and ventricular volumes over time.

RESULTS

The maximum ventricular volume was up to 12 times that of baseline. One animal developed acute hydrocephalus on day 4. All other animals survived until planned endpoints. The interaction between volume of blood injected and duration of injection was significantly associated with clot volume on the postoperative scan (p = 0.003) but not the amount of blood injected alone (p = 0.38). Initial postoperative and day 7 clot volumes, but not volume of blood injected, were correlated with maximum (p = 0.007 and 0.014) and terminal (p = 0.014 and 0.036) ventricular volumes. Initial postoperative ventricular volume was correlated with maximum and terminal ventricular volume (p = 0.007 and p = 0.014).

CONCLUSIONS

Initial postoperative, maximum, and terminal ventricular dilations were associated with the amount of clot formed, rather than the amount of blood injected. This supports the hypothesis that PHVD is determined by clot burden rather than the presence of blood products and allows further testing of early clot lysis to minimize PHVD risk.