gms | German Medical Science

Objective: Implantable pulsatile ventricular assist devices have proven to be successful to bridge time to transplantation in patients with therapy resistant heart failure or as permanent therapy option in patients who cannot be listed for heart transplantation. Anticoagulation is a prerequisite condition in these patients, most frequently with coumarin derivatives. Little is known about the frequency and outcome of neurosurgical emergencies in these patients.

Methods: In the Department of Cardiothoracic, Transplantation and Vascular Surgery 627 Left Ventricular Assist Devices (LVADs) were implanted between January 2005 and November 2017. All patients who had a neurosurgical emergency procedure were identified and evaluated retrospectively.

Results: Between January 2005 and November 2017, 35 neurosurgical emergencies appeared in 31 patients with LVADs. Age at implantation ranged between 1 year and 77 years. The period of time between LVAD implantation and the neurosurgical emergency ranged between 8 months and 8 years after LVAD implantation. In 34 emergency cases the patients sustained an intracranial hemorrhage, which in 22 patients was treated operatively via craniotomy (10), burrhole (1), craniectomy (5) or placement of external ventricular drain (6). Seven patients had a thromboembolic stroke, 6 of them accompanied by intracranial hemorrhage and 1 with brain swelling. Intracerebral hemorrhage was found in 23 patients (9 frontal, 4 temporal, 6 parietal, 1 occipital and 3 cerebellar). In 10 of these patients the intracerebral hemorrhage was accompanied by intraventricular hemorrhage. Five patients suffered from subdural hematoma, 4 acute and 1 chronic subdural hematoma. Six patients had a subarachnoid hemorrhage, 4 of them traumatic and 2 spontaneous. Fourteen of the 31 patients died, 12 of them suffer from permanent disabilities and 5 recovered well.

Conclusion: The two neurosurgical main emergencies in patients with LVADs are intracranial hemorrhage and thromboembolic stroke with brain swelling and secondary hemorrhage. According to our database, neurosurgical emergencies occured in 35/627 (5.6%) of patients and neurosurgical emergency procedures were performed in 22/627 (3.5%) of patients over a 12-year period. Both intracranial hemorrhage and ischemic strokes are associated with high mortality and morbidity in these patients.