From Risk Factors to Action: Preventing Stroke After Durable LVAD in the Contemporary Era

1/3 https://e-kcj.orgStroke remains one of the most devastating adverse events after durable left ventricular assist device (LVAD) implantation, often reshaping a patient's candidacy for heart transplantation, long-term quality of life, and survival.As mechanical circulatory support expands in advanced heart failure care, durable LVAD therapy has become an integral option within contemporary heart failure management pathways. 1)2)With longer durations of support and broader patient eligibility, preventing neurologic complications has become a core determinant of "success" for LVAD programs-affecting not only survival but also functional recovery, rehabilitation burden, and the ability to remain active on transplant waiting lists.In this issue of the Korean Circulation Journal, Wan and colleagues 3) present a systematic review and meta-analysis of risk factors for post-LVAD stroke, pooling data from 34 studies and 65,962 patients.Their work is timely because it consolidates fragmented literature into interpretable signals and explicitly addresses the device-era transition, a critical lens when discussing hemocompatibility and stroke risk.Beyond estimating associations, the analysis helps clinicians distinguish baseline vulnerabilities from "on-support" events that may be preventable through structured care pathways.Across their pooled analyses, the strongest associations with post-LVAD stroke were pump thrombosis (odds ratio [OR], 3.26) and infection (OR, 2.44), whereas atrial fibrillation was not associated with stroke risk (OR, 0.93). 3)Other factors with smaller but statistically significant associations included advanced age, peripheral vascular disease, cancer, chronic obstructive pulmonary disease, lower albumin, and lower international normalized ratio (INR). 3)These findings invite 2 critical observations and 1 practical implication: many of the most powerful signals reflect complications that arise during support, suggesting that stroke risk is dynamic and potentially modifiable over time rather than fixed at implantation.First, the "infection-thrombosis-stroke axis" dominates the clinical landscape.The magnitude of association for infection and pump thrombosis substantially exceeds most baseline comorbidities, underscoring that many LVAD strokes are tightly coupled to events occurring during support rather than pre-implant characteristics alone. 3)This reframes stroke prevention as an ongoing systems problem involving driveline care protocols, early recognition of bacteremia, and consistent anticoagulation infrastructure. 4)In practice,