Introduction: While current guidelines recommend waiting a minimum of 4 weeks for a cardiac transplant following a major ischemic or hemorrhagic stroke, there are currently no guidelines to define severity. Here we discuss two case of same-day transplant following acute ischemic stroke. Methods: In this two case series we present adult patients with cardiomyopathy who are pending imminent heart transplant. The first is a 62 year with a bioprosthetic mitral valve repair and ischemic cardiomyopathy (EF 5-10%) hospitalized with worsening heart failure symptoms. On the day of scheduled heart transplant, he developed acute onset left sided numbness and mild left sided weakness (NIHSS 3). CT head was unremarkable, CT angiography head/neck revealed an occlusion of the right distal superior M2 division with increased Tmax in the right parietal lobe (Figure 1). after risk benefit discussions with the cardiac, stroke neurology team, patient and family, he underwent a successful orthotopic heart transplant. There was no neurological worsening after surgery and he was discharged from the hospital several weeks after the heart transplant. The second patient is a 70 year old with ischemic cardiomyopathy admitted for expedited heart transplant evaluation developed acute onset left arm weakness (NIHSS 2). CTH showed a hypodensity in the right temporo-parietal region with increased Tmax and a normal CT angiography of the head/neck (Figure 2). A donor heart became available and after a multidisciplinary discussion, he underwent a cardiac transplant on the same day. A repeat CT head on the following day showed expected evolution of the infarct without hemorrhagic transformation, and also showed small left cerebellar hypodensities concerning for additional infarcts. Discussion: These cases underscore the importance of multidisciplinary risk-benefit discussion when determining whether acute stroke would preclude planned transplant surgery. Conversations will include risk of: 1) additional ischemic stroke in the setting of severely reduced ejection fractions and using LV assistive devices, 2) risk of hemorrhagic transformation of the ischemic stroke when patients are exposed to high doses of systemic heparin during surgery. And 3) risk of alteration in cerebral perfusion during anesthesia and cardiopulmonary bypass. Acute stroke should not immediately preclude heart transplant but instead activate a conversation between stroke neurology, cardiology, and cardiac surgery teams.
Safonova et al. (Thu,) studied this question.