Stroke and Left Ventricular Assist Device (LVAD)

Treatment of ischemic stroke for a patient on left ventricular assist device (LVAD) by neurointerventional means is rare and many anesthesia providers are unfamiliar with both LVAD and neurointerventional protocols. Examples of this include: 1) filling for continuous-flow LVAD depend on preload and the flow is inversely related to afterload; as mean arterial pressure (MAP) increases above 80 to 90 mm Hg, flow decreases; 2) there may be no palpable pulse in patients with continuous flow LVADs; 3) pulse oximetry may not work when pump flow is high and native myocardial function is minimal; 4) increasing MAP above 80 mm Hg potentially will maintain ischemic brain tissue—the penumbra—until flow is restored. This latter example creates a paradoxical management goal: increasing the mean arterial pressure (MAP) above 80 mm Hg while maintaining ischemic brain tissue, may decrease flow to the LVAD. Finally, there is controversy regarding which type of anesthesia is most efficacious for neuro interventional procedures. We describe three patients on LVAD suffering ischemic stroke requiring anesthesia for embolectomy and angioplasty during neurointerventional radiology procedures.