Pre-Operative Intracardiac Thrombus is Associated with Increased Risk of Stroke and Death in CF-LVAD Patients

Purpose Advanced heart failure predisposes patients to intracardiac thrombus (ICT) formation. There is a paucity of evidence examining the impact of pre-existing left atrial (LA) or left ventricular (LV) thrombi on post-operative outcomes in patients undergoing durable LVAD implantation. Methods We retrospectively reviewed 525 LVAD patients (374 HMII, 151 HM3) from 2/2009 through 3/2019. Transthoracic echocardiography (TTE) within 1 month of implant, intra-operative transesophageal echocardiography (TEE), and operative reports were reviewed to identify patients with pre-existing ICT at the time of LVAD surgery. The primary outcome was a composite of stroke or death at 6 months. Results Of the 525 patients (age 58±1 years, 81.5% male, 46% ICM) who underwent device implantation during the study period, 41 (7.8%) had a pre-existing ICT (16 in LA, 22 in LV and 3 in both). Patients with ICT had higher mortality (24.4% vs. 9.3%; p=0.002) and higher stroke rate (17.1% vs. 7.6%; p=0.036) at 6 months compared to patients without thrombus. Survival free from stroke and freedom from stroke in the two groups is shown in Figure 1a and 1b. In a multivariable model including age, gender, history of stroke, history of atrial fibrillation/flutter, atrial appendage ligation, and device type, ICT was found to be the only independent predictor of death or stroke at 6 months (HR 2.07, 95% CI 1.10 - 3.89). No stroke or deaths occurred in the 7 HM3 patients who had ICT prior to surgery. Conclusion Pre-existing ICT is associated with decreased survival free of stroke following LVAD implantation. Additional studies are warranted to assess the optimal risk stratification and management of these patients.