Carotid artery structure and hemodynamics and their association with adverse vascular events in left ventricular
Michael E Kiyatkin1, Amelia M Zuver2, Antonia Gaudig3
1Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA. mkiyatkin@montefiore.org.
Insights
Pre-existing carotid artery plaque and stenosis, identified before left ventricular assist device (LVAD) implantation, significantly increase the risk of major adverse vascular events like stroke and bleeding. LVAD therapy itself did not show a direct association with these outcomes in this study.
Area of Science:
- Cardiovascular Medicine
- Vascular Surgery
- Biomedical Engineering
Background:
- Left ventricular assist devices (LVADs) are crucial for advanced heart failure but are linked to serious vascular complications, including stroke and gastrointestinal bleeding (GIB).
- The underlying causes of these vascular events are thought to be pre-existing vascular dysfunction or alterations in blood flow dynamics introduced by continuous-flow LVADs.
Purpose of the Study:
- To investigate whether pre-existing large artery atherosclerosis, assessed via carotid ultrasonography, is associated with post-LVAD implantation adverse vascular outcomes.
- To determine if abnormal blood flow patterns in the carotid arteries correlate with an increased risk of stroke, GIB, or death after LVAD surgery.
Main Methods:
- Retrospective analysis of 141 adult HeartMate II LVAD patients.
- Carotid ultrasound duplex examinations were used to assess structural parameters (plaque burden, stenosis) and hemodynamic parameters (velocities, pulsatility index) pre- and/or post-implantation.
- Association between pre-operative carotid findings and a composite outcome (stroke, GIB, death) was analyzed, adjusting for known risk factors.
Main Results:
- Pre-operative moderate-to-severe carotid plaque was significantly associated with the composite adverse outcome (OR 5.08).
- Pre-operative internal carotid artery stenosis showed a strong association with the composite outcome (OR 9.02).
- Altered hemodynamic parameters measured during LVAD support were not found to be associated with the composite adverse outcome.
Conclusions:
- Pre-existing atherosclerosis, particularly moderate-to-severe carotid plaque and stenosis, is a significant predictor of adverse vascular events following LVAD implantation.
- While LVAD hemodynamics did not directly correlate with adverse outcomes in this study, the combination of pre-existing atherosclerosis and LVAD support may contribute to complications.
- Pre-operative assessment of carotid artery morphology is crucial for risk stratification and patient management in individuals undergoing LVAD therapy.
Abstract:
Left ventricular assist devices (LVADs) are associated with major vascular complications including stroke and gastrointestinal bleeding (GIB). These adverse vascular events may be the result of widespread vascular dysfunction resulting from pre-LVAD abnormalities or continuous flow during LVAD therapy. We hypothesized that pre-existing large artery atherosclerosis and/or abnormal blood flow as measured in carotid arteries using ultrasonography are associated with a post-implantation composite adverse outcome including stroke, GIB, or death. We retrospectively studied 141 adult HeartMate II patients who had carotid ultrasound duplex exams performed before and/or after LVAD surgery. Structural parameters examined included plaque burden and stenosis. Hemodynamic parameters included peak-systolic, end-diastolic, and mean velocity as well as pulsatility index. We examined the association of these measures with the composite outcome as well as individual subcomponents such as stroke. After adjusting for established risk factors, the composite adverse outcome was associated with pre-operative moderate-to-severe carotid plaque (OR 5.08, 95% CI 1.67-15.52) as well as pre-operative internal carotid artery stenosis (OR 9.02, 95% CI 1.06-76.56). In contrast, altered hemodynamics during LVAD support were not associated with the composite outcome. Our findings suggest that pre-existing atherosclerosis possibly in combination with LVAD hemodynamics may be an important contributor to adverse vascular events during mechanical support. This encourages greater awareness of carotid morphology pre-operatively and further study of the interaction between hemodynamics, pulsatility, and structural arterial disease during LVAD support.
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