Postoperative Delirium is Associated with Increased Operative and One Year Mortality in Patients Treated

with Surgical and Transcatheter Aortic Valve Replacement

Hersh Maniar MD, Brian Lindman MD, Michael Avidan MD, Krisztina Escallier Eric Novac, Marci Damiano, John Lasala MD, Marc Moon MD

Spencer Melby MD, Nishath Quadar MD, Michael Pasque MD

Ralph Damiano MD, Alan Zajarias MD

Divisions of Cardiology and Cardiothoracic Surgery

Washington University School of Medicine

St. Louis, MO

Postoperative Delirium• Postoperative delirium (PD) is a well recognized

complication after cardiac surgery affecting up to 50% of patients

• PD has been associated with increased perioperative morbidity, hospital length of stay and perioperative mortality resulting in increased health care costs.

• Treatments for PD have had limited success and greater emphasis has been placed upon identifying high risk patients and prevention

Transcatheter Aortic Valve Replacement

• Increasingly adopted among high risk patients that are also at high risk for developing PD.

• Several high profile randomized trials have been performed comparing surgical aortic valve replacement (SAVR) to transcatheter aortic valve replacement (TAVR).

• None have addressed whether utilization of TAVR has impacted the incidence of PD or its associated negative outcomes.

Study Outline

• Evaluate the incidence of PD after TAVR and SAVR, examine adverse outcomes associated with PD and explore risk factors for the development of PD after either procedure

• 427 patients underwent either TAVR (n=168) or SAVR (n=159) for isolated severe aortic stenosis

• PD was assessed by the Confusion Assessment Method for the ICU (CAM-ICU).

• Perioperative outcomes and one-year mortality were evaluated in patients with and without PD

CAM-ICU

• (1) Change from baseline• (2) Inattention• (3) Disorganized thinking• (4) Altered level of consciousness

• Performed in conjunction with the Richmond Agitation Sedation Scale (RASS)

• Performed twice daily on intubated/awake patients

• 90% specificity and 70% sensitivity

TAVR and SAVR Demographics

  TAVR (n=168) SAVR (n=259) p value

Age 81± 8 71 ± 11 <0.001

Female 92 (55%) 108 (42%) 0.010

BMI 27.5 ± 6.3 31 ± 8 <0.001

STS-PROM 9.3 (6.1,13.5) 3.0 (1.5,6.0) <0.001

ASA class ≥ 4 162 (96%) 180 (70%) <0.001

NYHA 3 or 4 147 (88%) 139 (54%) <0.001

DM 72 (43%) 95 (37%) 0.22

HTN 156 (93%) 209 (81%) <0.001

CAD 143 (85%) 114 (44%) <0.001

CVD 52 (31%) 57 (22%) 0.04

AF 65 (39%) 49 (19%) <0.001

CLD (moderate/severe) 59 (35%) 39 (15%) <0.001

PVD 113 (67%) 71 (27%) <0.001

EF (%) 53 ± 15 58 ± 14 0.002

Aortic Valve Gradient (mean) 44 ± 14 43 ± 14 0.70

Preoperative GFR 64.1 ±26.7 74.9 ± 25.9 <0.001

Hemoglobin 11.3 ±1.5 12.5 ± 1.9 <0.001

Albumin 4.0 ± 0.5 4.1 ± 0.4 0.12

Delirium Incidence in TAVR and SAVR

• PD was identified in 32% of patients (n=135)

• AVR type PD (%)

SAVR 33%

TAVR 29%

Transaortic/Tranaspical 35%

Transfemoral (TF) 18%

• PD was hypoactive (RASS <0) 53%

p=0.4

p=0.02

Delirium Incidence in TAVR and SAVR

• PD was identified in 32% of patients (n=135)

• AVR type PD (%)

SAVR 33%

TAVR 29%

Transaortic/Tranaspical 35%

Transfemoral (TF) 18%

• PD was hypoactive (RASS <0) 53%

p=0.03

Perioperative Complications

  TAVR SAVR

 No Delirium

(n=119)

Delirium

(n=49)p value

No Delirium

(n=173)

Delirium

(n=86)p value

Prolonged ventilation 2 (2%) 0 (0%) 1.0 10 (6%) 18 (21%) <0.001

Stroke 1(1%) 1 (2%) 0.5 1(1%) 1 (1%) 1.0

Acute Kidney Injury 8 (7%) 12 (24%) 0.003 25(14%) 15(17%) 0.003

Hospital length of stay 5 7 <0.001 7 9 <0.001

Initial ICU stay (hours) 26 50 <0.001 31 72 <0.001

Readmission to the ICU 4 (3%) 5 (10%) 0.12 2 (1%) 9 (10%) 0.001

Discharged to home 87 (73%) 26 (53%) 0.018 146 (84%) 49 (57%) <0.001

30 day survival 98% 88% 0.029 100% 95% 0.04

Delirium and Survival

Delirium and One Year Mortality

• Interaction between AVR type (TAVR vs. SAVR) and PD with respect to 1-year mortality (interaction p=0.12).

• The relationship between PD and post-AVR mortality was similar for TAVR and SAVR treated patients.

Variable HR 95% CI p-value

Delirium (yes) 3.023 (1.748, 5.228) <.001

TAVR (yes) 2.360 (1.269, 4.389) 0.007

Age (per 1 year) 1.006 (0.976, 1.036) 0.71

Female (yes) 0.580 (0.329, 1.023) 0.06

STS score (per 1 unit) 1.099 (1.054, 1.146) <.001

Summary

• PD is common after TAVR and SAVR occurring in nearly a third of patients

• TAVR-TF had the lowest incidence of PD when compared to any other procedure

• PD was associated with increased perioperative morbidity and mortality

• PD is associated with a 3-fold increase in mortality during the first year after valve replacement

Conclusion

• Given the high incidence of PD and its adverse consequences, further studies should be performed to confirm and extend these findings.

• Identify modifiable risk factors for PD to minimize PD occurrence and improve short term outcomes

• Whether reducing PD will improve longer term outcomes remains to be determined

Thank you for your attention