КРАТКИЕ СООБЩЕНИЯ
Клинический случай раннего
ишемического инсульта после установки вспомогательного левожелудочкового устройства (LVAD), успешно пролеченного с помощью механической экстракции тромба
Зоринас А.1, Янушаускас В.1, Гайжаускас Э.1, Гайжаускиене К.2, Урбонас К.3, Самалавичус Р.С.3, Ручинскас К.1
1 Клиника сердечно-сосудистых заболеваний, Институт клинической медицины, медицинский факультет Университета Вильнюса, 04816, г. Вильнюс, Литовская Республика
2 Кафедра радиологии, ядерной медицины и медицинской физики, Университет Вильнюса, 04816, г. Вильнюс, Литовская Республика
3 Клиника неотложной медицинской помощи, Институт клинической медицины, медицинский факультет Университета Вильнюса, 04816, г. Вильнюс, Литовская Республика
ДЛЯ КОРРЕСПОНДЕНЦИИ
Зоринас Алексей - MD, врач, клиника сердечно-сосудистых заболеваний Института клинической медицины, медицинский факультет Университета Вильнюса (Вильнюс, Литовская Республика) E-mail: aleksejus.zorinas@santa.lt https://orcid.org/0000-0001-6845-7080
Актуальность. Левожелудочковые вспомогательные устройства (1_УА0) все чаще используются у пациентов с прогрессирующей сердечной недостаточностью (СН) для увеличения продолжительности и улучшения качества жизни. Однако даже при использовании центробежных помп последнего поколения с полностью магнитной левитацией защита пациента от церебральных тромбоэмболических осложнений, ассоциирующихся с инвалидизацией, по-прежнему остается сложной задачей. В позднем послеоперационном периоде пациенты, перенесшие установку 1_УА0, могут получать тромболитические препараты, в то время как в раннем послеоперационном периоде после установки 1_УА0 эти препараты противопоказаны. В настоящей статье представлен клинический случай острого ишемического инсульта, развившегося через несколько часов после установки 1_УА0. Пациент был успешно пролечен с помощью механической экстракции тромба.
Цель - привлечь внимания хирургов и реаниматологов к ишемическим цереброваскулярным осложнениям в раннем послеоперационном периоде после установки 1_УА0. Кроме того, представлен эффективный подход, своевременное применение которого позволяет не допустить отдаленной неврологической инвалидизации.
Ключевые слова:
сердечная недостаточность, левожелудочковое вспомогательное устройство (ШАО), ишемический инсульт
Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов в отношении настоящей публикации.
Для цитирования: Зоринас А., Янушаускас В., Гайжаускас Э., Гайжаускиене К., Урбонас К., Самалавичус Р.С., Ручинскас К. Клинический случай раннего ишемического инсульта после установки вспомогательного левожелудочкового устройства (1_\/А0), успешно пролеченного с помощью механической экстракции тромба // Клиническая и экспериментальная хирургия. Журнал имени академика Б.В. Петровского. 2020. Т. 8, № 3. С. 119-122. 001: https://doi.org/10.33029/2308-1198-2020-8-3-119-122 (англ.)
Статья поступила в редакцию 16.07.2020. Принята в печать 25.08.2020.
A case of early ischemic stroke after LVAD implantation successfully treated with mechanical thrombus extraction
OORRESPONDENCE
Aleksejus Zorinas - MD, PhD, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University (Vilnius, Republic of Lithuania) E-mail: aleksejus.zorinas@santa.lt https://orcid.org/0000-0001-6845-7080
Zorinas A.1, Janusauskas V.1, Gaizauskas E.1, Gaizauskiene K.2, Urbonas K.3, SamaLavicius R.S.3, Rucinskas K.1
1 Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, 04816, Vilnius, Republic of Lithuania
2 Department of Radiology, Nuclear Medicine and Physics of Medicine, Vilnius University, 04816, Vilnius, Republic of Lithuania
3 Clinic of Emergency Medicine, Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, 04816, Vilnius, Republic of Lithuania
Keywords:
heart failure, Left ventricular assist device, ischemic stroke
Background. Left ventricular assist devices (LVAD) are increasingly used for patients with advanced heart failure (HF) improving life expectancy and quality of life. However, even with the latest generation fully magnetically levitated centrifugal-flow pumps, cerebral thromboembolic events remain one of the major challenges to keep patients free of impairment. While late post-op LVAD patients can be treated with thrombolytic agents, it is contraindicated in the early period after LVAD implantation. We report a case of an acute ischemic stroke several hours after LVAD implantation, successfully treated with mechanical thrombus extraction.
Aim of this clinical report is to attract attention of the surgeons and intensive therapy physicians on ischemic cerebrovascular complication at the early postoperative course after LVAD implantation. In addition, to present timely effective treatment modality resulting in no long-term neurologic disability.
Funding. The study had no sponsor support.
Conflict of interest. Authors declare no conflicts of interest in regards to this publication.
For citation: Zorinas A., Janusauskas V., Gaizauskas E., Gaizauskiene K., Urbonas K., Samalavicius R.S., Rucinskas K. A case of early ischemic stroke after LVAD implantation successfully treated with mechanical thrombus extraction. Clinical and Experimental Surgery. Petrovsky Journal. 2020; 8 (3): 119-22. DOI: https://doi.org/10.33029/2308-1198-2020-8-3-119-122 Received 16.07.2020. Accepted 25.08.2020.
A 32 years old socially and physically active female with no previously known comorbidities has presented to tertiary hospital with shortness of breath at rest, progressive weakness and dry cough.
Fig. 1. Computed tomography of cerebral perfusion showing wide penumbra with no ischemic core zone on the right cerebral hemisphere
On admission, she was conscious and alert, pale with cool clammy peripheries. Her respiratory rate was 26 breaths per minute. Electrocardiogram revealed sinus rhythm with rate of 100 beats per minute. According to the patient, she had no diuresis for the past 12 hours. A patient underwent urgent transthoracic echocardiogram. It revealed severely impaired and enlarged left ventricle. Patient was admitted to hospital, a diagnosis of dilated cardiomyopathy resulting severe heart failure (NYHA class IV) was made.
She received an optimal medical treatment with loop and potassium sparing diuretics, angiotensin-converting-enzyme inhibitor and p-Receptor blockers. Despite that management her clinical symptoms deteriorated rapidly and the patient was transferred to intensive therapy unit were intravenous pi-agonist (Dobutamine) was initiated. A given treatment has not improved patient's clinical status and she was sliding into INTERMACS class II [1]. It allowed clinicians to put the patient on the heart transplant-awaiting list.
Зоринас А., Янушаускас В., Гайжаускас Э., Гайжаускиене К., Урбонас К., Самалавичус Р.С., Ручинскас К. ■ КЛИНИЧЕСКИЙ СЛУЧАЙ РАННЕГО ИШЕМИЧЕСКОГО ИНСУЛЬТА ПОСЛЕ УСТАНОВКИ ВСПОМОГАТЕЛЬНОГО ЛЕВОЖЕЛУДОЧКОВОГО _УСТРОЙСТВА (LVAD), УСПЕШНО ПРОЛЕЧЕННОГО С ПОМОЩЬЮ МЕХАНИЧЕСКОЙ ЭКСТРАКЦИИ ТРОМБА
Patients clinical symptoms continued to deteriorate rapidly and fully magnetically levitated centrifugal-flow pump was implanted (HeartMate 3, Abbott). The operation was performed in the routine manner, through median sternotomy, on beating heart and completed without any incident or complications. After procedure the patient transferred to the intensive care unit with mild inotrope doses.
After 4 hours sedation was discontinued and weakness of the left upper and lower limbs was noticed. Computed tomography (CT) perfusion and CT scan angiography were performed, revealing right middle cerebral artery (M1) thrombosis (ASPECTS 10) and wide penumbra with no ischemic core zone (f'g. 1 and 2).
Mechanical thrombus extraction was performed in the catheterization laboratory by the interventional radiologist using 6x25 mm stent retriever restoring blood flow to the right middle cerebral artery (Thrombolysis in Cerebral Infarction [TICI] score = 3) (fig. 3 and 4).
Patient limb strength fully recovered within two days with no residual symptoms. Further down the clinical course of the patient was relatively uneventful and she was discharged to rehabilitation facility on the 20th postoperative day. 21 months after LVAD implantation the patient is well, she returned to her normal social and physical activities. She continues to attend scheduled outpatient visits; no other cerebrovascular episodes occurred or were documented.
Fig. 2. Computed tomography scan angiography revealing occlusion of the right middle cerebral artery (M1) (arrow) and no blood flow to distal arteries (circle)
Fig. 3. Thrombosis in the right middle cerebral artery (M1)
Discussion
Cerebral thromboembolic complications in LVAD patients, despite reduced incidents of stroke with the newest generation devices, remain a difficult challenge, keeping patients with no disability. Even with the latest fully magnetically levitated technology ischemic stroke incidence may reach 6.5% [2]. Regarding long-term, LVAD patients in time have a risk of developing ischemic stroke, as a result of atrial fibrillation, pump thrombosis, systemic infection, inadequate antithrombotic treatment [3]. Although these risk factors increase chances of ischemic cerebrovascular events in the long-term after LVAD implantation, in the first days after the procedure theoretically they are less likely to take place. In our case, the patient had none of the risk factors mentioned above, LVAD implantation performed without any procedural complications, exact onset of the stroke symptoms was unknown, and it leaves only to speculate on the cerebral thrombosis etiology.
The treatment options for ischemic stroke include intravenous thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rtPA), intra-arterial thrombolysis in patients major
Fig. 4. Completely restored blood flow to the right middle cerebral artery (TICI score 3) with Trevo XP Stentriever 6x25 mm
stroke onset less than 6 hours' due to occlusions of the MCA and who is not otherwise candidates for intravenous rtPA, and mechanical thrombus extraction [4, 5].
In our case thrombolysis was contraindicated since the operation was executed on the same day,
which could lead to major bleeding. Regardless of the unexplained etiology and unclear thromboembolic event time, to avoid unfavorable neurological sequel immediate treatment had to be performed. Mechanical thrombus removal was the most suitable choice for immediate restoration of the blood flow to an occluded cerebral artery decreasing chances of irreversible changes in brain tissue.
Conclusion
Despite the progress of LVAD's in reducing the risk of stroke, cerebral thromboembolic events remain an undesirable possibility and often are disabling and/ or life threatening. Early stroke incident after LVAD implantation eliminates the method of thrombolytic therapy, as could lead to major bleeding. Urgent mechanical thrombus extraction is encouraged, having favorable results in symptoms-free recovery.
References
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2. Colombo P.C., Mehra M.R., Goldstein D.J., et al. Comprehensive Analysis of Stroke in the Long-Term Cohort of the MOMENTUM 3 Study: A Randomized Controlled Trial of the HeartMate 3 Versus the HeartMate II Cardiac Pump. Circulation. 2019; 139 (2): 155-68. DOI: https:// doi.org/10.1161/CIRCULATI0NAHA.118.037231
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