Managing Intracranial Hemorrhage in Patients with a Durable Continuous Flow Left Ventricular Assist Device

Abstract

Background While intracranial hemorrhage (ICH) is a known complication of left ventricular assist device (LVAD) support, and is associated with high morbidity and mortality, optimal care pathways have neither been elucidated nor reported. We describe management of LVAD patients following ICH, with a focus on anticoagulation, operative interventions, care team designation, complications, and outcomes. Methods We retrospectively reviewed all durable continuous-flow LVAD implantations at our academic medical center from January 2007 to July 2018. Patients who experienced ICH after LVAD were identified. We defined baseline and ICH characteristics, medical and surgical interventions, care teams, and outcomes including death, device thrombosis, ischemic stroke, and hemorrhage expansion. Results A total of 321 patients underwent LVAD implantation during the study period, and 27 (8%) developed ICH (17 intraparenchymal, 7 subdural, 2 subarachnoid, 1 intraventricular) while on support. Twenty-five were anticoagulated at onset of bleed. Of those, 13 were managed with immediate cessation of anticoagulation and administration of reversal products (Group A). Group A had a median of 6 days off anticoagulation and 60 days of follow up with 1 patient (8%) developing device thrombosis at day 8, 1 (8%) developing subsequent ischemic stroke at day 14, and 4 (31%) with ICH expansion. Seven patients had anticoagulation stopped at onset of bleed without administration of reversal products (Group B). With a median of 2 days off anticoagulation and 2 days of follow up, no patients in Group B developed ischemic stroke or device thrombosis while 1 (14%) had ICH expansion. Five patients had anticoagulation continued at onset of bleed (Group C) with a median follow up of 330 days. One (20%) developed device thrombosis at day 5 while 2 (40%) developed ICH expansion. Four patients with subdural hemorrhage underwent Burr hole drainage with all 4 surviving to discharge. Two patients with intraparenchymal hemorrhage underwent open craniotomy with neither surviving to discharge. An interdisciplinary discussion occurred in all cases. Following ICH, only one-third of patients in the study survived to 6 months. Conclusion LVAD patients who experience an ICH have variable outcomes. Their care is multidisciplinary and can involve operative intervention. The discontinuation and reversal of anticoagulation is generally well-tolerated, with a low risk for early device thrombosis. Like for many hemorrhagic complications of LVADs, ICH often persists or worsens. Additional investigation is needed to elucidate the most optimal management strategies.