title: Risk factors, mortality, and timing of ischemic and hemorrhagic stroke with left ventricular assist devices.
abstract: BACKGROUND
  Stroke is a major cause of mortality after left ventricular assist device (LVAD) placement.
  
  
  METHODS
  Prospectively collected data of patients with HeartMate II (n = 332) and HeartWare (n = 70) LVADs from October 21, 2004, to May 19, 2015, were reviewed. Predictors of early (during index hospitalization) and late (post-discharge) ischemic and hemorrhagic stroke and association of stroke subtypes with mortality were assessed.
  
  
  RESULTS
  Of 402 patients, 83 strokes occurred in 69 patients (17%; 0.14 events per patient-year [EPPY]): early ischemic stroke in 18/402 (4%; 0.03 EPPY), early hemorrhagic stroke in 11/402 (3%; 0.02 EPPY), late ischemic stroke in 25/402 (6%; 0.04 EPPY) and late hemorrhagic stroke in 29/402 (7%; 0.05 EPPY). Risk of stroke and death among patients with stroke was bimodal with highest risks immediately post-implant and increasing again 9-12 months later. Risk of death declined over time in patients without stroke. Modifiable stroke risk factors varied according to timing and stroke type, including tobacco use, bacteremia, pump thrombosis, pump infection, and hypertension (all p < 0.05). In multivariable analysis, early hemorrhagic stroke (adjusted odds ratio [aOR] 4.3, 95% confidence interval [CI] 1.0-17.8, p = 0.04), late ischemic stroke (aOR 3.2, 95% CI 1.1-9.0, p = 0.03), and late hemorrhagic stroke (aOR 3.7, 95% CI 1.5-9.2, p = 0.005) predicted death, whereas early ischemic stroke did not.
  
  
  CONCLUSIONS
  Stroke is a leading cause and predictor of death in patients with LVADs. Risk of stroke and death among patients with stroke is bimodal, with highest risk at time of implant and increasing risk again after 9-12 months. Management of modifiable risk factors may reduce stroke and mortality rates.
authors.affiliation: Department of Neurology, New York University, New York, New York. Electronic address: frontej@ccf.org.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Frontera
authors.affiliation: Kaufman Center for Heart Failure and Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Randall
authors.initials: R
authors.lastname: Starling
authors.affiliation: Department of Neurology, New York University, New York, New York.
authors.forename: Sung-Min
authors.initials: SM
authors.lastname: Cho
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amy S
authors.initials: AS
authors.lastname: Nowacki
authors.affiliation: Department of Neurology, New York University, New York, New York.
authors.forename: Ken
authors.initials: K
authors.lastname: Uchino
authors.affiliation: Department of Neurology, New York University, New York, New York.
authors.forename: M Shazam
authors.initials: MS
authors.lastname: Hussain
authors.affiliation: Kaufman Center for Heart Failure and Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Maria
authors.initials: M
authors.lastname: Mountis
authors.affiliation: Kaufman Center for Heart Failure and Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Nader
authors.initials: N
authors.lastname: Moazami
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002545:Brain Ischemia / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D020300:Intracranial Hemorrhages / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011475:Prosthesis Failure; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Left ventricular assist device; hemorrhagic stroke; intracranial hemorrhage; ischemic stroke; mortality risk factors; stroke