Stroke Research and Treatment
Volume 2019 (2019), Article ID 4695414, 6 pages
https://doi.org/10.1155/2019/4695414

Research Article

Heart Failure Is Not Associated with a Poor Outcome after Mechanical Thrombectomy in Large Vessel Occlusion of Cerebral Arteries

Marlena Schnieder,¹ Anneki von Glasenapp,1,2 Amelie Hesse,³ Marios N. Psychogios,³ Mathias Bähr,¹ Gerd Hasenfuß,² Marco R. Schroeter,² and Jan Liman¹

¹Department of Neurology, University Medical Center Göttingen, 37075 Göttingen, Germany
²Clinic of Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, 37075 Göttingen, Germany
³Department of Neuroradiology, University Medical Center Göttingen, 37075 Göttingen, Germany

Correspondence should be addressed to Marlena Schnieder; marlena.schnieder@med.uni-goettingen.de

Received 11 May 2019; Accepted 4 July 2019; Published 1 August 2019

Academic Editor: Francisco Campos

Copyright © 2019 Marlena Schnieder et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

The impact of heart failure on outcome in stroke patients is not fully understood. There is evidence for an increased mortality and morbidity, but it remains uncertain whether thrombectomy in patients with large vessel occlusion (LVO) in the anterior circulation is less effective in patients with heart failure compared to patients without. Retrospectively, we analyzed echocardiographic data of all patients in our stroke database, who underwent mechanical thrombectomy (n=668) for the presence of heart failure. Furthermore, we collected baseline characteristics and neurological and neuroradiological parameters. In the analysis, 373 of the 668 patients of our stroke database underwent echocardiography. Of these 373 patients, 90 patients (24%) suffered from heart failure with reduced left ventricular ejection fraction measured by echocardiography according to the current guidelines. After adjustment for age, the Alberta stroke program early CT score (ASPECTS), and time from symptom onset to recanalization, the analysis revealed that thrombectomy in patients with heart failure and LVO is not associated with less favorable outcome measured by the modified Rankin Scale after 90 days (3 (0-6) vs. 3 (1-5); p=0.380). Moreover, we could not find a significant difference in mortality compared to patients without heart failure (11.0% vs. 7.4%; p=0.313).

1. Introduction

Heart failure is a disease associated with a high mortality and morbidity [1, 2]. Moreover, most of the patients with symptomatic heart failure suffer from comorbidities, such as peripheral artery embolism, pulmonary embolism, and stroke, leading to a higher mortality [3].

The risk of stroke in heart failure increases with the severity of heart failure, and patients with a moderate heart failure have an annual risk of stroke of approximately 1.5% [4], leading up to a risk of 4% in severe heart failure [5].

Because ischemic stroke and heart failure share common risk factors, such as diabetes and arterial hypertension [6], interactions between the two diseases are likely. Moreover, heart failure leads to a hypercoagulate state with rheological alterations due to decreased blood flow [7] leading to a higher rate of stroke in patients with heart failure compared to the normal population [8]. These patients also have a higher incidence of atrial fibrillation and the risk of atrial fibrillation could vice versa increase the severity of heart failure [9]. It has been shown that, in patients with heart failure suffering from stroke, outcome is worse compared to those without heart failure, displayed by higher mortality, but also reduced neurological functional outcome [10]. Patients with heart failure may have a worse outcome after mechanical thrombectomy, since it could be shown that these patients have a poorer collateral-status regarding the blood supply of the brain compared to the patients without heart failure [11].

In contrast the analysis of the VISTA cohort could show that systemic thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) is as effective in patients with heart failure as in those without [12].

Thus, it remains uncertain whether mechanical thrombectomy in patients with large vessel occlusion is less effective in patients with heart failure compared to patients with normal systolic left ventricular heart function.

2. Methods

We retrospectively analyzed the echocardiographic data of patients of our prospectively kept stroke database, regarding the presence of heart failure. Patients were classified as suffering from heart failure when showing a reduced ejection fraction < 55% in the echocardiography.

The collected data includes neurological features as the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) and neuroradiological data such as the Alberta stroke program early CT score (ASPECTS) and the Collateral Status. The NIHSS and the mRS were assessed by experienced stroke neurologist and the ASPECTS and the collateral stroke by a senior neuroradiologist. The rate of symptomatic intracranial hemorrhage was collected as well. A symptomatic intracranial hemorrhage was defined as a deterioration of ≥ 4 in the NIHSS [13]. Furthermore, we collected the cardiovascular risk factors (CVRF) as well as long-term holter electrocardiographic data and duplex sonography of the brain-supplying arteries. Antiplatelet medication and anticoagulation were collected as well as heart failure medication.

Transthoracic echocardiography was performed by experienced cardiological examiners using a standard operating procedure (IE33, CX50 and X7-2t probe (Philips Medical Systems, Eindhoven, Netherlands) or Vivid E9 and 6VT-D probe (GE Healthcare, USA)). We collected echocardiography data such as the ejection fraction, the diameter of atrial and ventricle, wall motion abnormalities, patent foramen ovale, and valve insufficiencies and stenosis. The valve insufficiencies and stenosis were further graduated into mild, moderate, and severe.

The statistical analysis was performed in IBM SPSS Statistics 24 package (IBM, Armonk, New York, USA). Descriptive analysis was descripted in relative frequencies using mean and median and standard deviation or the interquartile range. Group comparisons were performed using chi-square test. If they are not normally distributed, Mann-Whitney U-Test was performed. Multivariate regression analysis was performed to analyze the impact of the heart failure on the outcome of the patients. Possible baseline characteristics associated with the outcome (p<0.1) were included in the analysis. A backwards selection was then applied to find the best set of predictors. A p-value of < 0.05 was considered statistically significant.

3. Results

We screened 668 patients of our prospectively kept stroke database of patients with a large vessel occlusion who underwent mechanical thrombectomy for the presence of heart failure and further echocardiological characteristics. In total 373 (55.8%) patients underwent echocardiography. 90 (24%) of these patients suffered from heart failure with an impaired left ventricular systolic ejection fraction < 55%.

When comparing patients with and without heart failure, patients with heart failure are significantly older (77 (70-84) vs. 73 (63-83) years; p=0.011) and cardiovascular risk factors such as atrial fibrillation (50 (61.0%) vs. 81 (35.5%); p=< 0.001), peripheral artery disease (9 (11.0%) vs. 5 (2.2%); p=0.003), and coronary heart disease (44 (53.7%) vs. 41 (18.0%); p=<0.001) were significantly more frequent as well as chronic renal failure (27 (35.8%) vs. 35 (18.2%); p=0.003) (Table 1). Interestingly there were no differences in rates of pretreatment antiplatelet medication (21 (34.4%) vs. 53 (33.1%); p = 0.874) or oral anticoagulants (6 (17.1%) vs. 29 (18.1%); p = 0.153) in patients with heart failure compared to those without.

Table 1: Baseline characteristics of patients with and without heart failure.

Baseline characteristics and cardiovascular risk factors
Normal systolic LV-ejection fraction
Heart failure with reduced ejection fraction
p-value

Age
73 (63-83)
77 (70-84)
0.011

Female
126 (53.8%)
41 (48.8%)
0.428

Male
108 (46.2%)
43 (51.2 %)

Arterial Hypertension
182 (79.1%)
71 (85.5%)
0.203

Diabetes mellitus
53 (23.1%)
27 (32.9%)
0.082

Atrial fibrillation
81 (35.5%)
50 (61.0%)
< 0.001

Obesity
71 (33.0%)
33 (41.8%)
0.164

Dyslipidemia
101 (43.9%)
41 (50.6%)
0.298

Smoking
46 (22.7%)
12 (16.9%)
0.307

Peripheral artery disease
5 (2.2%)
9 (11.0%)
0.003

Coronary heart disease
41 (18.0%)
44 (53.7%)
<0.001

Chronic renal failure
35 (18.2%)
24 (35.8%)
0.003

As expected, patients with heart failure had more cardiac comorbidities. Using echocardiography, we found that patients with heart failure suffer more often from heart valve insufficiencies (aortic insufficiency (39 (61.9%) vs. 83 (42.1%); p=0.009); mitral valve insufficiency (78 (95.1%) vs. 181 (81.2%); p=0.003); tricuspid valve insufficiency (69 (90.8%) vs. 164 (74.5%); p= 0.003)). When looking at the severity of valve insufficiencies especially, the difference becomes manifest. Patients with heart failure significantly suffer more often from severe mitral valve insufficiency (9 (90 %) vs. 1 (10 %); p < 0.001) and severe tricuspid valve insufficiency (8 (72.7%) vs. 3 (27.3%); p < 0.001).

Furthermore, dilatation of ventricles and atria were significantly more present in patients with heart failure comparing to those without (end diastolic left ventricular dilatation (15 (21.7%) vs. 2 (1%); p<0.001); left atrial dilatation (64 (91.4%) vs. 103 (58.5%); p<0.001); right ventricular dilatation (14 (40%) vs. 12 (10.5%); p<0.001); right atrial dilatation (7 (77.8%) vs. 8 (19%); p= 0.001)) (Table 2).

Table 2: Echocardiological characteristics of patients with and without hear failure.

Echocardiographic characteristics
Normal systolic LV-ejection fraction
Heart failure with reduced ejection fraction
p-value

Posterior wall thickness (mm, median, IQR)
12 (10.5-13.5)
12 (10.5-13.5)
0.559

Left ventricular enddiastolic volume (ml, median, IQR)
43 (39.5-46.5)
46 (40-52)
0.001

Left ventricular endsystolic volume (ml, median, IQR)
25 (21-29)
31 (26-36)
0.001

Left atrial diameter (mm, median, IQR)
34 (29.5-38.5)
42 (37.5-46.5)
<0.001

Aortic sinus (mm, median, IQR)
30 (26.5-33.5)
30 (26.5-33.5)
0.454

Left ventricular ejection fraction (%,median, IQR)
55 (55-55)
44.5 (35.5-53.5)
<0.001

Left ventricular hypertrophy
138 (70.4%)
49 (69.0%)
0.826

Left ventricular dilatation
2 (1%)
15 (21.7%)
<0.001

Left atrial dilatation
103 (58.5%)
64 (91.4%)
<0.001

Right ventricular dilatation
12 (10.5%
14 (40%)
<0.001

Right atrial dilatation
8 (19%)
7 (77.8%)
0.001

Wall motion abnormalities
5 (2.6%)
53 (72.6%)
<0.001

Congested inferior vena cava
15 (8.8%)
22 (34.4%)
<0.001

Aortic insufficiency
83 (42.1%)
39 (61.9%)
0.009

Aortic valve stenosis
25 (15.1%)
10 (16.4%)
0.805

Mitral valve sclerosis
30 (26.5%)
10 (38.5%)
0.237

Mitral valve insufficiency
181 (81.2%)
78 (95.1%)
0.003

Pulmonary valve insufficiency
47 (40.9%)
14 (58.3%)
0.174

Tricuspid valve insufficiency
164 (74.5%)
69 (90.8%)
0.003

Thrombus in the Left atrial appendage
4 (4.4%)
2 (8.3%)
0.440

Endocarditis
1 (2.8%)
1 (10%)
0.391

Patent foramen ovale
33 (18.9%)
5 (11.4%)
0.275

The neuroradiological characteristics did not differ between the two groups. There was no difference especially at the initial CCT-ASPECTS (8 (7-9) vs. 9 (8-10); p=0.155) or the collateral-status of the patients assessed by the Menon score (7 (5.5-8.5) vs. 7 (5-9); p=0.906).

Looking closer at the neurological characteristics of the severity of the stroke, there is no difference of the NIHSS at admission (15 (10.5-19.5) vs. 15 (10.5-19.5); p=0.085) and there is no difference regarding the NIHSS at discharge (6.5 (0-13) vs. 5 (0-10.5); p=0.324) or in the mRS at discharge (3 (1-5) vs. 3 (1-5); p=0.238) or at 90 days after stroke (3 (0-6) vs. 3 (1-5); p=0.380). After dichotomizing the mRS in patients with a favorable outcome as mRS of 0-2 and an unfavorable outcome for mRS 3-6 there is still no difference in patients with heart failure and without (32 (43.8%) vs. 105 (48.2%); p=0.521). We did not find a higher mortality either (9 (11.0%) vs. 17 (7.4%); p=0.313) (Table 3).

Table 3: Neurological characteristics of patients with and without heart failure.

Neurological and neuroradiological characteristics
Normal systolic LV-ejection fraction
Heart failure with reduced ejection fraction
p-value

Neurological Characteristics

NIHSS at admission (median, IQR)
15 (10.5-19.5)
15 (10.5-19.5)
0.085

NIHSS at discharge (median, IQR)
5 (0-10.5)
6.5 (0-13)
0.324

mRS at admission  
(median, IQR)
5 (4-6)
5 (4-6)
0.174

mRS at discharge  
(median, IQR)
3 (1-5)
3 (1-5)
0.238

mRS after 90 days (median, IQR)
3 (1-5)
3 (1-5)
0.380

Favorable Outcome
105 (48.2%)
32 (43.8%)
0.521

Intravenous rt-PA
160 (68.7%)
51 (60.7%)
0.185

Hemicraniectomy
9 (4.7%)
7 (10.3%)
0.098

Symptomatic Intracranial Hemorrhage
2 (1%)
3 (4.4%)
0.080

Mortality
17 (7.4%)
9 (11%)
0.313

Toast criteria

<0.001

Macroangiopathy
23 (12.2%)
4 (5.9%)

Cardio-embolic
82 (43.6%)
53 (77.9%)

other
11 (5.9%)
1 (1.5%)

unknown
44 (23.4%)
5 (7.4%)

ESUS
28 (14.9%)
5 (7.4%)

Neuroradiological Characteristics

TICI-Scale

0.177

0
15 (6.6%)
5 (6.0%)

1
8 (3.5%)
8 (9.6%)

2a
31 (13.5%)
7 (8.4%)

2b
117 (51.1%)
39 (47%)

3
58 (25.3%)
24 (28.9%)

CT-ASPECTS (median, IQR)
9 (8-10)
8 (7-9)
0.155

Collateral Status (median, IQR)
7 (5-9)
7 (5.5-8.5)
0.906

Symptom onset to recanalization (min, median, IQR)
220 (159-281)
246 (176-316)
0.341

Occlusion site

0.326

Proximal carotid artery
8 (3.4%)
2 (2.4%)

Distal carotid artery
39 (16.8%)
17 (20.5%)

M1
135 (58.2%)
41 (49.4%)

M2
25 (10.8%)
14 (16.9%)

Basilar artery
24 (10.3%)
7 (8.4%)

Posterior cerebral artery
1 (0.4%)
1 (1.2%)

Anterior cerebral artery
0 (0.0%)
1 (1.2%)

IQR: interquartile range, rt-PA: recombinant tissue plasminogen activator, NIHSS: National Institute of Health Stroke Scale, mRS: modified Rankin Scale, ESUS: embolic stroke of unknown source, TICI: thrombolysis in cerebral infarction, and CT-ASPECTS: computer tomography-Alberta Stroke program early CT score.

This is also reflected in the multivariate regression analysis where no influence of heart failure on outcome of the patients could be demonstrated (RR - 0.001; 95% CI: (-0.011-0.009); p=0.860) (Table 4).

Table 4: Regression analysis regarding predictors of a good outcome (mRS 0-2) in patients with mechanical thrombectomy in LVO.

Outcome
RR
95% Confidence
Interval
p-value

Age
0.10
0.004
0.017
0.004

Occlusion side
-0.037
-0.178
0.104
0.606

Intravenous rt-PA
0.135
-0.059
0.328
0.171

Coronary heart disease
0.146
-0.066
0.357
0.174

Chronic renal failure
-0.109
-0.345
0.126
0.359

NIHSS at admission
0.016
0.000
0.032
0.044

Symptom onset to recanalization
0.001
0.000
0.002
0.021

TICI Scale
-0.125
-0.229
-0.021
0.019

CT-ASPECTS
-0.015
-0.085
0.054
0.665

Collateral Score
-0.027
-0.072
0.017
0.222

HFrEF
-0.001
-0.011
0.009
0.860

Left ventricular hypertrophy
-0.020
-0.206
0.165
0.828

RR: relative risk, rt-PA: recombinant tissue plasminogen activator, NIHSS: National Institute of Health Stroke Scale, TICI: thrombolysis in cerebral infarction, CT-ASPECTS: computer tomography-Alberta Stroke program early CT score, HRrEF: heart failure with reduced ejection fraction, mRS: modified Rankin Scale, and LVO: large vessel occlusion.

4. Discussion

We could show that mechanical thrombectomy is as effective in patients with heart failure as in those without. Heart failure does not have an impact on neurological outcome after large vessel occlusion when treated with mechanical thrombectomy. These findings are coherent to the analysis of the VISTA cohort, in which it was shown that systemic thrombolysis is effective, regardless of the presence of heart failure [12]. Even though it had been shown that patients with heart failure experience a higher mortality and morbidity after stroke [14]. One possible explanation might be the impaired cerebral perfusion due to the compromised ejection fraction, leading to poorer baseline collateral status, which is associated with worse outcome in patients with LVO [11]. In our study, we could not find an impact of heart failure on the cerebral collateral status of the patients; patients with heart failure did show similar collateral status, measured by the Menon score, compared to patients without heart failure. Another factor often blamed for possible worse outcome of HF patients after stroke is that symptomatic intracranial bleedings after systemic thrombolysis are more common in patients with heart failure [15]. In contrast, we did not detect a higher rate of symptomatic intracranial bleedings after mechanical thrombectomy and the proportion of patients also receiving systemic thrombolysis was not different in either group. One statistical drawback might be that the rate of intracranial bleedings after mechanical thrombectomy was very low and potential differences may not have been detected due to the small number of intracranial bleedings.

The strength of this study is the sample size and the well characterized patient cohort with comprehensive data especially regarding the neurological and neuroradiological parameters, as well as a 90-day followup examination. A limitation is the retrospective character of the study. Furthermore, we only included patients with a reduced ejection fraction, and we did not include patients with heart failure with a preserved ejection fraction and diastolic dysfunction. Thus, there is a probability of inclusion of some of those patients into the control group, which might influence our results.

5. Conclusion

In our study heart failure is not associated with a poorer outcome or higher mortality after mechanical thrombectomy in LVO. The NIHSS at discharge and mRS at 90 days as well as the mortality are similar in the two groups of patients. Even though patients with heart failure suffer from a high morbidity and mortality in stroke, they seem to benefit from cerebral artery recanalization therapy just as patients without heart failure.

Data Availability

The data used to support the findings of this study are available from the corresponding author upon request.

Disclosure

A part of the data was presented at the European Stroke Organisation Conference in 2018.

Conflicts of Interest

Marios N. Psychogios received honoraria and travel from grants Penumbra Inc., honoraria from Phenox GmbH, is a consultant to Stryker Neurovascular and Siemens Healthineers, and has a research agreement with Siemens Healthineers. Jan Liman received Speaker or Advisory Board fees from Pfizer, BMS, Bayer Healthcare, Stryker, and Daichii Sankyo.

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