Stroke Incidence and Impact of Continuous-Flow Left Ventricular Assist Devices on Cerebrovascular Physiology

While advancements in left ventricular assist devices (LVAD) have led to improved survival1–5, complications associated with longterm exposure to continuous-flow (CF) circulatory support, such as gastrointestinal bleeding, pump thrombosis and stroke result in significant morbidity. Strokes affect 10% of patients in the first year of support alone.6 Management algorithms for CF-LVAD patients suffering from stroke have been published previously.7 In this article, we summarize the clinical burden of strokes placed in context of other complications, comorbidities, and medication-effects that work together in an almost synergistic fashion to increase the risk of stroke. Physiologic (mal)adaptations to continuous-flow circulatory support are reviewed with an emphasis on the arterial baroreceptor reflex, neurohumoral axis and implications on blood pressure control. Cerebral perfusion and autoregulatory processes in the setting of heart failure with reduced ejection fraction (HFrEF), hypertension and CF-LVAD support are discussed. Finally, we highlight important areas of future research that will advance our understanding of the physiology of this unique patient population, and pave the way for novel management strategies to prevent strokes in CF-LVAD patients.