Stroke and the total artificial heart: neurologic considerations.

Neurologic complications, particularly brain infarction (ischemic stroke), are frequent and serious sequelae of total artificial heart (TAH) implantation. Most strokes that occur in TAH patients are due to embolism of thrombotic fragments originating on prosthetic surfaces. The emboli tend to lodge in the middle cerebral artery or its cortical branches and cause cortical syndromes. Cardioembolic strokes are characteristically heralded by the abrupt onset of a maximal neurologic deficit in an awake, often active patient. Cardioembolic strokes have a tendency to undergo hemorrhagic transformation. Anticoagulation is a major issue in stroke management: In anticoagulated patients, hemorrhagic transformation often results in major neurologic worsening; therefore, this risk must be weighed against the danger of recurrent embolism in the absence of anticoagulation. We recommend avoiding anticoagulation during the initial 24 to 48 hours after a stroke, especially in patients with large cardioembolic infarcts. Because of the many invasive procedures producing bacteremia in TAH patients, combined with the large area of prosthetic surfaces, infective endocarditis is a potential concern. Weighing the risks and benefits of anticoagulation in patients with infective endocarditis is likely to produce a controversial choice. Anticoagulation should probably be continued in such patients if they have total artificial hearts. The following article discusses the foregoing issues and presents recommendations for managing acute stroke in TAH patients.