Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta‐analysis

Abstract

Aims To perform an updated systematic review and meta‐analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). Methods We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. Results A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%–11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%–23.7%). According to the level of evidence and results of meta‐analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non‐transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79–2.71; pooled adjusted RR: 1.62, 95% CI: 1.25–2.10), particularly long‐term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91–4.23; pooled adjusted HR: 1.88, 95% CI: 1.30–2.73). Conclusions POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.

Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review

“…In our meta-regression analysis, the absence of age and sex influences on the GA-POD link is interesting. Advanced age and male sex are well-established risk factors for POD based on previous research 11 . The lack of association in this meta-regression analysis suggests that GA exposure may increase the risk of POD regardless of age and sex in patients undergoing TAVR.…”

“…Besides inflammatory response that has been proposed to be a contributor to POD 7 , several modifiable and non-modifiable risk factors were identified in a recent large-scale meta-analysis of 69 studies focusing on patients undergoing TAVR without exposure to surgery-induced inflammatory response 11 . Non-modifiable predisposing factors included advanced age, prior stroke/transient ischemic attack, male gender, and postoperative acute kidney injury, atrial fibrillation/flutter, and impaired Instrumental Activities of Daily Living 11 , while modifiable risk factors consisted of GA exposure, weight loss, electrolyte imbalance, and techniques of TAVR (e.g., www.nature.com/scientificreports/ non-transfemoral Access) 11 . Despite the inclusion of up to 69 studies in that meta-analysis, it involved only nine studies with 3,555 patients when assessing the impact of GA on the risk POD 11 .…”

“…Non-modifiable predisposing factors included advanced age, prior stroke/transient ischemic attack, male gender, and postoperative acute kidney injury, atrial fibrillation/flutter, and impaired Instrumental Activities of Daily Living 11 , while modifiable risk factors consisted of GA exposure, weight loss, electrolyte imbalance, and techniques of TAVR (e.g., www.nature.com/scientificreports/ non-transfemoral Access) 11 . Despite the inclusion of up to 69 studies in that meta-analysis, it involved only nine studies with 3,555 patients when assessing the impact of GA on the risk POD 11 . In contrast, our investigation included 17 studies involving 10,678 patients.…”

“…There may be several possible explanations for the association between GA exposure and an elevated POD risk in the current meta-analysis (i.e., OR = 1.846). First, old age is a known risk factor for POD 11 . A previous study reported a positive correlation between an increasing age and the occurrence of POD with the incidence of POD being 22% in patients aged 50-59 but up to 92% in those aged 80-89 53 .…”

The Association of Infection with Delirium in the Post-Operative Period after Elective CABG Surgery

“…In a 2021 meta-analysis by Chen et al analysing 14 studies with a total sample size of 13,286, the following risk factors for postoperative delirium in cardiac surgery patients were identified: age, carotid artery stenosis, depression, diabetes, NYHA functional class III or IV, duration of mechanical ventilation and length of ICU stay [17]. In their 2022 meta-analysis on postoperative delirium after transcatheter aortic valve replacement, Ma et al identified the following risk factors for delirium: increased age, male sex, prior stroke or TIA, atrial fibrillation/flutter, weight loss, electrolyte abnormality, general anaesthesia and postoperative acute kidney injury [18]. Similarly, in our study, older age and worse overall preoperative condition were found to be associated with a higher incidence of postoperative delirium.…”