Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality

Abstract

Objective The purpose of this study was to determine the incidence and clinical significance of postoperative delirium (PD) in patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). Method Between 2010 and 2013, 427 patients underwent TAVR (n = 168) or SAVR (n = 259) and were screened for PD using the Confusion Assessment Method for the Intensive Care Unit. The incidence of PD in both treatment groups was determined and its association with morbidity and mortality was retrospectively compared. Results PD occurred in 135 patients (32%) with a similar incidence between SAVR (33% [86 out of 259]) and TAVR (29% [49 out of 168]) (P = .40). TAVR by transfemoral approach had the lowest incidence of PD compared with SAVR (18% vs 33%; P = .025) or TAVR when performed by alternative access techniques (18% vs 35%; P = .02). Delirium was associated with longer initial intensive care unit stay (70 vs 27 hours), intensive care unit readmission (10% [14 out of 135] vs 2% [6 out of 292]), and longer hospital stay (8 vs 6 days) (P < .001 for all). PD was associated with increased mortality at 30 days (7% vs 1%; P < .001) and 1 year (21% vs 8%; P < .001). After multivariable adjustment, PD remained associated with increased 1-year mortality (hazard ratio, 3.02; 95% confidence interval, 1.75–5.23; P < .001). There was no interaction between PD and aortic valve replacement approach with respect to 1-year mortality (P = .12). Among propensity-matched patients (n = 170), SAVR-treated patients had a higher incidence of PD than TAVR-treated patients (51% vs 29%; P = .004). Conclusions PD occurs commonly after SAVR and TAVR and is associated with increased morbidity and mortality. Given the high incidence of PD and its associated adverse outcomes, further studies are needed to minimize PD and potentially improve patient outcomes.

Postoperative Delirium in Individuals Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta‐Analysis

“…Several hypotheses have been postulated, including neurotransmitter imbalances, inflammatory processes, and physiologic stress. Advanced age and multiple comorbidities are also known risk factors for development of delirium, although we could not find associations between incidence of IHPOD after TAVR and mean age, percentage of participants treated with non‐TF access, and logistic EuroSCORE. Our metaregression was performed at the study level, with lack of participant‐level data; thus, considering the mean values of tested variables (and not individual data) from included studies; such limitations may have reduced the power of our metaregression to find similar associations.…”

“…The majority of participants included in our meta‐analysis were derived from 2 large prospective registries, with the lack of information regarding delirium diagnostic criteria and timing of the delirium screening . Interestingly, while these 2 large studies reported lower incidence of IHPOD after TAVR (e.g., 3.8% and 4.6%), small studies included in our analysis report higher incidence of IHPOD after TAVR . Several participant‐ and procedural‐related factors, including age at admission, comorbid condition, TAVR access, and hospital complication rate, could explain the differences in the incidence of IHPOD between these studies.…”

“…Seven studies reported IHPOD according to the CAM, for a total of 682 patients (Figure ) . The pooled estimate rate of CAM‐defined IHPOD was 13.5% (95% CI=4.9–22.1%), with evidence of high interstudy heterogeneity (Q = 151; I = 96%; p heterogeneity < .001).…”

333 Slow gait speed and rapid renal function decline are risk factors for postoperative delirium after urological surgery

“…Incidence peaks of kidney, urinary bladder and prostate cancers were around 60-80 years of age. Because the development of delirium in surgical patients has been associated with negative outcomes including a higher risk of postoperative mortality, [2,7,8] geriatric assessment in older patients with genitourinary cancers, and management of postoperative delirium is an important issue. [9] However, only few studies included very few patients have evaluated postoperative delirium incidences after urological surgery.…”

Costs of postoperative delirium with transcatheter aortic valve replacement: Improved yet still present

“…In patients over 65 years of age undergoing cardiac surgery, postoperative delirium has a reported incidence of 26 to 52%. The estimated incremental cost of PD after cardiac surgery is 150 billion dollars annually in the United States . TAVR patients had 29% incidence of PD in the best study to date .…”