Skip to main content
SpringerLink
Log in

Stroke Risk Following Infection in Patients with Continuous-Flow Left Ventricular Assist Device

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

Infection has been associated with stroke in patients with left ventricular assist devices (LVAD); however, 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 infection 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 multivariable 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 association 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 < 0.001). There was a trend toward shorter stroke-free survival among patients with LVAD infection.

Conclusions

LVAD infections, particularly BSI, are significantly associated with stroke, and infection-related stroke conferred significantly lower cumulative survival.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume ED, et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transpl. 2015;34(12):1495–504.

    Article  Google Scholar 

  2. O’Horo JC, Abu Saleh OM, Stulak JM, Wilhelm MP, Baddour LM, Sohail MR. Left ventricular assist device infections: a systematic review. ASAIO J. 2018;64(3):287–94.

    Article  Google Scholar 

  3. Kilic A. The future of left ventricular assist devices. J Thorac Dis. 2015;7(12):2188–93.

    PubMed  PubMed Central  Google Scholar 

  4. Palm F, Urbanek C, Grau A. Infection, its treatment and the risk for stroke. Curr Vasc Pharmacol. 2009;7(2):146–52.

    Article  CAS  Google Scholar 

  5. Vahedi K, Amarenco P. Cardiac causes of stroke. Curr Treat Options Neurol. 2000;2(4):305–18.

    Article  CAS  Google Scholar 

  6. Carod Artal FJ. Clinical management of infectious cerebral vasculitides. Expert Rev Neurother. 2016;16(2):205–21.

    Article  CAS  Google Scholar 

  7. Johnson TP, Nath A. Neurological syndromes driven by postinfectious processes or unrecognized persistent infections. Curr Opin Neurol. 2018;31(3):318–24.

    Article  Google Scholar 

  8. Cho SM, Rice C, Marquardt RJ, Zhang LQ, Khoury J, Thatikunta P, et al. Magnetic resonance imaging susceptibility-weighted imaging lesion and contrast enhancement may represent infectious intracranial aneurysm in infective endocarditis. Cerebrovasc Dis. 2017;44(3–4):210–6.

    Article  Google Scholar 

  9. Ruttmann E, Willeit J, Ulmer H, Chevtchik O, Höfer D, Poewe W, et al. Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke. 2006;37(8):2094–9.

    Article  Google Scholar 

  10. Frontera JA, Starling R, Cho SM, Nowacki AS, Uchino K, Hussain MS, et al. Risk factors, mortality, and timing of ischemic and hemorrhagic stroke with left ventricular assist devices. J Heart Lung Transpl. 2017;36(6):673–83.

    Article  Google Scholar 

  11. Aggarwal A, Gupta A, Kumar S, Baumblatt JA, Pauwaa S, Gallagher C, et al. Are blood stream infections associated with an increased risk of hemorrhagic stroke in patients with a left ventricular assist device? ASAIO J. 2012;58(5):509–13.

    Article  CAS  Google Scholar 

  12. Trachtenberg BH, Cordero-Reyes AM, Aldeiri M, Alvarez P, Bhimaraj A, Ashrith G, et al. Persistent blood stream infection in patients supported with a continuous-flow left ventricular assist device is associated with an increased risk of cerebrovascular accidents. J Card Fail. 2015;21(2):119–25.

    Article  Google Scholar 

  13. Yoshioka D, Sakaniwa R, Toda K, Samura T, Saito S, Kashiyama N, et al. Relationship between bacteremia and hemorrhagic stroke in patients with continuous-flow left ventricular assist device. Circ J. 2018;82(2):448–56.

    Article  Google Scholar 

  14. Merkler AE, Chu SY, Lerario MP, Navi BB, Kamel H. Temporal relationship between infective endocarditis and stroke. Neurology. 2015;85(6):512–6.

    Article  Google Scholar 

  15. INTERMACS. Appendix A Adverse event definitions. http://www.uab.edu/medicine/intermacs/intermacs-documents. Accessed 10 January 2018.

  16. Kirklin JK, Pagani FD, Kormos RL, Stevenson LW, Blume ED, Myers SL, et al. Eighth annual INTERMACS report: special focus on framing the impact of adverse events. J Heart Lung Transpl Off Publ Int Soc Heart Transpl. 2017;36(10):1080–6.

    Article  Google Scholar 

  17. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309–32.

    Article  Google Scholar 

  18. Snygg-Martin U, Gustafsson L, Rosengren L, Alsiö A, Ackerholm P, Andersson R, et al. Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis. 2008;47(1):23–30.

    Article  Google Scholar 

  19. Røder BL, Wandall DA, Espersen F, Frimodt-Møller N, Skinhøj P, Rosdahl VT. Neurologic manifestations in Staphylococcus aureus endocarditis: a review of 260 bacteremic cases in nondrug addicts. Am J Med. 1997;102(4):379–86.

    Article  Google Scholar 

  20. Cho IJ, Kim JS, Chang HJ, Kim YJ, Lee SC, Choi JH, et al. Prediction of hemorrhagic transformation following embolic stroke in patients with prosthetic valve endocarditis. J Cardiovasc Ultrasound. 2013;21(3):123–9.

    Article  Google Scholar 

  21. Mahesh B, Angelini G, Caputo M, Jin XY, Bryan A. Prosthetic valve endocarditis. Ann Thorac Surg. 2005;80(3):1151–8.

    Article  Google Scholar 

  22. Meeteren JV, Maltais S, Dunlay SM, Haglund NA, Beth Davis M, Cowger J, et al. A multi-institutional outcome analysis of patients undergoing left ventricular assist device implantation stratified by sex and race. J Heart Lung Transpl. 2017;36(1):64–70.

    Article  Google Scholar 

  23. Cagliostro B, Levin AP, Fried J, Stewart S, Parkis G, Mody KP, et al. Continuous-flow left ventricular assist devices and usefulness of a standardized strategy to reduce drive-line infections. J Heart Lung Transpl. 2016;35(1):108–14.

    Article  Google Scholar 

  24. Hasin T, Matsuzawa Y, Guddeti RR, Aoki T, Kwon TG, Schettle S, et al. Attenuation in peripheral endothelial function after continuous flow left ventricular assist device therapy is associated with cardiovascular adverse events. Circ J. 2015;79(4):770–7.

    Article  Google Scholar 

  25. Ellis ME, Al-Abdely H, Sandridge A, Greer W, Ventura W. Fungal endocarditis: evidence in the world literature, 1965–1995. Clin Infect Dis. 2001;32(1):50–62.

    Article  CAS  Google Scholar 

  26. Tahsili-Fahadan P, Curfman DR, Davis AA, Yahyavi-Firouz-Abadi N, Rivera-Lara L, Nassif ME, et al. Cerebrovascular events after continuous-flow left ventricular assist devices. Neurocrit Care. 2018;29(2):225–32.

    Article  CAS  Google Scholar 

Download references

Funding

No targeted funding reported.

Author information

Authors and Affiliations

  1. Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Sung-Min Cho

  2. Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA

    Sung-Min Cho & Jennifer A. Frontera

  3. Cardiothoracic Surgery (NM), NYU School of Medicine, New York, NY, USA

    Nader Moazami

  4. Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA

    Nader Moazami

  5. Department of Cardiology, NYU School of Medicine, New York, NY, USA

    Stuart Katz

  6. Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA

    Adarsh Bhimraj & Nabin K. Shrestha

  7. Department of Neurology, NYU School of Medicine, New York, NY, USA

    Jennifer A. Frontera

  8. NYU Department of Neurology, 150 55th St., Brooklyn, NY, 11231, USA

    Jennifer A. Frontera

Authors
  1. Sung-Min Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nader Moazami
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stuart Katz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Adarsh Bhimraj
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nabin K. Shrestha
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jennifer A. Frontera
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SMC and JAF contributed to study concept and design. SMC and JAF contributed to data acquisition and analysis. JAF reviewed and finalized the statistical analysis. SMC prepared the first draft of the manuscript. SK, AB, NM and NKS contributed to drafting the manuscript. SMC and JAF finalized the manuscript.

Corresponding author

Correspondence to Jennifer A. Frontera.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical Approval

This study was approved by the Cleveland Clinic IRB, and all patients or their surrogates consented to participation.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 85 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cho, SM., Moazami, N., Katz, S. et al. Stroke Risk Following Infection in Patients with Continuous-Flow Left Ventricular Assist Device. Neurocrit Care 31, 72–80 (2019). https://doi.org/10.1007/s12028-018-0662-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-018-0662-1

Keywords

Search

Navigation