Tenecteplase for Acute Ischemic Stroke in a Left Ventricular Assist Device Patient: A Case Report and Protocol Framework
Dawn Ullmann1, Andrew Ullmann2, Amie Hsia3, Sana Somani4
1Neurology, 2Cardiology, WALTER REED NATIONAL MILITARY MEDICAL CENTER, 3Neurology, MedStar Health / MedStar Washington Hospital Center, 4Neurology, Medstar Washington Hospital Center
Objective:
To describe the first reported case of tenecteplase (TNK) use for acute ischemic stroke (AIS) in a patient with a continuous-flow left ventricular assist device (CF-LVAD), guided by a predefined institutional protocol.
Background:
CF-LVADs carry a high risk of thromboembolic stroke due to altered hemodynamics and prothrombotic physiology. Systemic thrombolysis is rarely pursued in this population because of elevated bleeding risk from the aforementioned physiologic changes and therapeutic anticoagulation, and current guidelines do not provide LVAD-specific recommendations. To our knowledge, TNK use has not been reported for AIS in an LVAD recipient.
Design/Methods:
Case report of a 56-year-old man with left ventricular noncompaction (LVNC), American College of Cardiology (ACC) stage D heart failure status post HeartMate 3 CF-LVAD (implanted 3 months prior), prior left ventricular thrombus, atrial flutter, patent foramen ovale, and remote
right middle cerebral artery (MCA) infarct without residual deficits presented 3.5 hours after sudden onset left hemiparesis and dysarthria (NIHSS 6). Neuroimaging included CT angiography (no large-vessel occlusion) and CT perfusion (right temporal area mismatch). INR was 1.2 while on warfarin (goal 2.0-3.0). Following multidisciplinary evaluation, TNK 0.25 mg/kg was administered per institutional protocol. Post-thrombolysis blood pressure was managed with invasive monitoring, targeting mean arterial pressure 70–90 mmHg.
Results:
The patient experienced rapid improvement, achieving NIHSS 0 at discharge. No hemorrhagic complications or LVAD dysfunction occurred during hospitalization.
Conclusions:
This case illustrates the complexity of AIS management in CF-LVAD patients, where anticoagulation and unique hemodynamics pose challenges for reperfusion therapy. TNK may offer advantages over alteplase, including single bolus dosing, increased fibrin specificity, and operational simplicity. To our knowledge, this is the first reported case of successful TNK use for AIS in a CF-LVAD recipient, demonstrating feasibility within a protocol-driven, multidisciplinary framework. Broader adoption requires further prospective data to define safety, selection criteria, and comparative efficacy versus alteplase and mechanical thrombectomy.
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