The role of cerebral hyperperfusion in postoperative neurologic dysfunction after left ventricular assist device implantation for end-stage heart failure

Lietz, Katherine; Brown, Kevin; Ali, Syed S.; Colvin-Adams, Monica; Boyle, Andrew J.; Anderson, David; Weinberg, Alan D.; Miller, Leslie W.; Park, Soon; John, Ranjit; Lazar, Ronald M.

doi:10.1016/j.jtcvs.2008.11.034

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 137, Issue 4 , Pages 1012-1019, April 2009

The role of cerebral hyperperfusion in postoperative neurologic dysfunction after left ventricular assist device implantation for end-stage heart failure

Katherine Lietz, MD, PhD
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY
- Address for reprints: Katherine Lietz, MD, PhD, Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Medical Center, PH-12 Stem Rm 134, 622W 168th St, New York, NY 10032.
Kevin Brown, DO
- Department of Neurology, University of Minnesota, Minneapolis, Minn
Syed S. Ali, MD
- Division of Biostatistics, Columbia University Medical Center, New York, NY
Monica Colvin-Adams, MD
- Division of Cardiology, University of Minnesota, Minneapolis, Minn
Andrew J. Boyle, MD
- Division of Cardiology, University of Minnesota, Minneapolis, Minn
David Anderson, MD
- Department of Neurology, University of Minnesota, Minneapolis, Minn
Alan D. Weinberg, MS
- Division of Biostatistics, Columbia University Medical Center, New York, NY
Leslie W. Miller, MD
- Division of Cardiology, Georgetown University–Washington Hospital Center, Washington, DC
Soon Park, MD
- Division of Cardiothoracic Surgery, Mayo Clinic, Rochester, Minn
Ranjit John, MD
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minn
Ronald M. Lazar, PhD
- Department of Neurology, Columbia University Medical Center, New York, NY

Received 12 March 2008; received in revised form 19 October 2008; accepted 22 November 2008.

Objective

Cerebral hyperperfusion is a life-threatening syndrome that can occur in patients with chronically hypoperfused cerebral vasculature whose normal cerebral circulation was re-established after carotid endarterectomy or angioplasty. We sought to determine whether the abrupt restoration of perfusion to the brain after left ventricular assist device (LVAD) implantation produced similar syndromes.

Methods

We studied the role of increased systemic flow after LVAD implantation on neurologic dysfunction in 69 consecutive HeartMate XVE LVAD (Thoratec, Pleasanton, Calif) recipients from October 2001 through June 2006. Neurologic dysfunction was defined as postoperative permanent or transient central change in neurologic status, including confusion, focal neurologic deficits, visual changes, seizures, or coma for more than 24 hours within 30 days after LVAD implantation.

Results

We found that 19 (27.5%) patients had neurologic dysfunction, including encephalopathy (n = 11), coma (n = 3), and other complications (n = 5). The multivariate analysis showed that an increase in cardiac index from the preoperative baseline value (relative risk, 1.33 per 25% cardiac index increase; P = .01) and a previous coronary bypass operation (relative risk, 4.53; P = .02) were the only independent predictors of neurologic dysfunction. Reduction of left ventricular assist device flow in 16 of the 19 symptomatic patients led to improvement of symptoms in 14 (87%) patients.

Conclusions

Our findings showed that normal flow might overwhelm cerebral autoregulation in patients with severe heart failure, suggesting that cerebral hyperperfusion is possible in recipients of mechanical circulatory support with neurologic dysfunction.

Abbreviations and Acronyms: CI, cardiac index, CT, computed tomographic, IABP, intra-aortic balloon pump, LVAD, left ventricular assist device, ND, neurologic dysfunction, PRES, posterior reversible encephalopathy syndrome, RR, relative risk