INCIDENCE, PREDICTORS AND OUTCOMES OF STROKE FOLLOWING CARDIAC TRANSPLANTATION

Purpose Stroke after heart transplantation (HT) is a major cause of morbidity and mortality. Less is known about the risk factors associated with stroke in the current era of increasing HT being performed in older patients and with advances in immunosuppressive (IS) therapies. We aimed to determine the incidence, predictors and outcomes of stroke after HT. Methods We examined the incidence of ischemic and hemorrhagic strokes and associated outcomes in all consecutive adults who underwent HT between 1994 and 2016 at a single institution. Logistic regression was used to examine predictors of stroke. The association of stroke with all-cause mortality were examined using Cox proportional hazards regression. Stroke events that occurred within 30 days postoperatively were excluded from the analysis. Results Of 530 patients who underwent HT, 44 (8.3%) developed stroke [37 (7%) had an ischemic events and 7 (1.3%) had a hemorrhagic stroke]. A multivariate logistic regression analysis showed that diabetes mellitus (DM) (odds ratio [OR] 2.5, p=0.02), renal dysfunction (OR 2.3 per unit increase in creatinine, p=0.01), azathioprine (vs. mycophenolate mofetil) use (OR 2.0, p=0.04), and longer course of steroids (OR 1.1, per year of treatment, p=0.009) were independent predictors of a composite outcome of ischemic or hemorrhagic strokes. Conversion from calcineurin inhibitor (CNI) to sirolimus-based IS was not found to be associated with a significant change in the risk of stroke (hazard ratio [HR] 1.6, CI: 0.79-3.05, p=0.20) compared with CNI maintenance therapy. After a median follow-up of 8.10 years, post-HT strokewas significantly associated with increased risk of death (adjusted HR 1.8, CI; 1.23-2.72, p=0.003). Conclusion Stroke after HT is not uncommon and is associated with increased mortality. HT recipients with DM, renal dysfunction, and those treated with azathioprine or with longer course of steroids were at greater risk of stroke.