Acute Middle Cerebral Artery Occlusion in a Heart Transplant Candidate: Left Ventricular Assist Device, Chronic Anticoagulation, Complicated by Lower Gastrointestinal Bleeding, M1 Occlusion Treated by Single-Pass Thrombectomy, with Favorable Clinical Outcome

Left ventricular assist devices (LVADs) have become a mainstay of treatment for end-stage heart failure, either as destination therapy in patients not eligible for cardiac transplantation or as a bridge to transplantation in patients on the waiting list for cardiac transplantation. The continuous evolution of device types and strategies has improved survival among patients undergoing implantation; nonetheless, stroke remains a significant complication after any LVAD implantation. We present the case of a 57-year-old patient who underwent implantation of an LVAD as a bridge to heart transplant therapy. Four months after the surgery, he was admitted to the Cardiology Department due to lower gastrointestinal bleeding. Chronic anticoagulation treatment was temporarily suspended for anemia correction. On the second day of admission, the patient suffered a major left-hemispheric stroke with a baseline National Institutes of Health Stroke Score (NIHSS) of 21. The Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast head CT was 10. CT angiography showed a cut-off in the M1 segment of the left MCA. CT perfusion revealed a sizeable ischemic penumbra with no evidence of core. The patient underwent successful endovascular revascularization of the left MCA occlusion. The procedure was uneventful. Repeat cranial CT showed an ischemic stroke in the left MCA territory with a post-thrombectomy ASPECTS of 8. Treatment with low-molecular weight heparin (LMWH) was started 24 h after the procedure, and treatment with coumadin was resumed within 7 days. Capsule endoscopy was unremarkable, and the hemoglobin level was stable. Upon discharge, the patient had an excellent clinical outcome with NIHSS of 1 and mRS of 2. This chapter describes the characteristics and outcomes of strokes complicating LVAD implantation.