Objectives

Management of left ventricular assist device (LVAD)-associated intracranial hemorrhage (ICH) is complicated by the competing concerns of hematoma expansion and the risk of thrombosis. Strategies include reversal or withholding of anticoagulation (AC) and neurosurgical (NSG) interventions. The consequences of these decisions can significantly impact both short- and long-term survival. Currently no guidelines exist. We reviewed medical and NSG practices following LVAD-associated ICH and analyzed outcomes.

Materials and methods

Retrospective analysis of data collected between 2012–2018 was performed. Survival probability following ICH was calculated using the Kaplan-Meier method.

Results

Out of 283 patients, 32 (11%) had 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%). IPH tended to occur sooner (median 138 [IQR 48 – 258] days post-LVAD placement) and be more neurologically devastating (mean GCS 11.4 [4.4]). Antithrombotics were reversed in 27 (79%); 1 thrombotic event occurred while off AC. Following resumption, re-hemorrhage occurred in 7 (25%), a median of 13 days (IQR 8-30) post-ICH. Five underwent NSG intervention and 6 (18%) went on to receive heart transplant. Overall, 30-day mortality was 26% (38% in IPH, 0% in SDH, and 29% in SAH), but rose to 44% at 6 months.

Conclusion

ICH is a common post-LVAD complication with high short- and long-term mortality, though ICH subtypes may not be equally devastating. Despite this, some may benefit from neurosurgical intervention and do well following cardiac transplant. Anticoagulation is frequently reversed after ICH. Resumption however should be approached cautiously in patients with LVADs given their possible baseline coagulopathy.

中文翻译：

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左心室辅助装置相关颅内出血的内科和外科治疗

目标

左心室辅助装置 (LVAD) 相关颅内出血 (ICH) 的管理因血肿扩大和血栓形成风险等相互竞争的担忧而变得复杂。策略包括逆转或停止抗凝 (AC) 和神经外科 (NSG) 干预。这些决定的后果会显着影响短期和长期生存。目前没有指导方针。我们回顾了 LVAD 相关 ICH 后的医学和 NSG 实践并分析了结果。

材料和方法

对 2012-2018 年间收集的数据进行了回顾性分析。使用 Kaplan-Meier 方法计算 ICH 后的生存概率。

结果

在 283 名患者中，32 名（11%）有 34 例 ICH：16 例脑实质内（IPH，47%），4 例硬膜下（SDH，12%）和 14 例蛛网膜下腔（SAH，41%）。IPH 往往发生得更早（LVAD 放置后中位数 138 [IQR 48 – 258] 天）并且对神经系统的破坏性更大（平均 GCS 11.4 [4.4]）。27 例（79%）的抗血栓药物被逆转；关闭 AC 时发生 1 起血栓事件。恢复后，再出血发生在 7 (25%)，中位时间为 13 天 (IQR 8-30) 后 ICH。5 人接受了 NSG 干预，6 人（18%）继续接受心脏移植。总体而言，30 天死亡率为 26%（IPH 为 38%，SDH 为 0%，SAH 为 29%），但在 6 个月时上升至 44%。

结论

ICH 是一种常见的 LVAD 后并发症，具有高短期和长期死亡率，尽管 ICH 亚型可能不会同样具有破坏性。尽管如此，有些人可能会从神经外科干预中受益，并在心脏移植后表现良好。ICH 后抗凝治疗经常被逆转。然而，考虑到 LVAD 患者可能存在基线凝血障碍，应谨慎对待恢复。