Delirium Incidence and Functional Outcomes After Transcatheter and Surgical Aortic Valve Replacement

Sandra M. Shi, MD; Minhee Sung, MD; Jonathan Afilalo, MD, MSc; Lewis A. Lipsitz, MD; Caroline A. Kim, MD, MPH; Jeffrey J. Popma, MD; Kamal R. Khabbaz, MD; Roger J. Laham, MD; Kimberly Guibone, NP; Jung Lee, BS; Edward R. Marcantonio, MD, SM; Dae Hyun Kim, MD, MPH, ScD

Disclosures

J Am Geriatr Soc. 2019;67(7):1393-1401. 

In This Article

Abstract and Introduction

Abstract

Background: Transcatheter aortic valve replacement (TAVR) may be associated with less delirium and allow faster recovery than surgical aortic valve replacement (SAVR).

Objective: To examine the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR.

Design: Prospective cohort study.

Setting: An academic medical center.

Participants: A total of 187 patients, aged 70 years and older, undergoing SAVR (N = 77) and TAVR (N = 110) in 2014 to 2016.

Measurements: Delirium was assessed daily using the Confusion Assessment Method (CAM), with severity measured by the CAM-Severity (CAM-S) score (range = 0-19). Outcomes were prolonged hospitalization (9 days or more); institutional discharge; and functional status, measured by ability to perform 22 daily activities and physical tasks over 12 months.

Results: SAVR patients had a higher incidence of delirium than TAVR patients (50.7% vs 25.5%; P < .001), despite younger mean age (77.9 vs 83.7 years) and higher baseline Mini-Mental State Examination score (26.9 vs 24.7). SAVR patients with delirium had a shorter duration (2.2 vs 3.4 days; P = .04) with a lower mean CAM-S score (4.5 vs 5.7; P = .01) than TAVR patients with delirium. The risk of prolonged hospitalization in no, mild, and severe delirium was 18.4%, 30.8%, and 61.5% after SAVR (P for trend = .009) and 26.8%, 38.5%, and 73.3% after TAVR (P for trend = .001), respectively. The risk of institutional discharge was 42.1%, 58.3%, and 84.6% after SAVR (P for trend = .01) and 32.5%, 69.2%, and 80.0% after TAVR (P for trend <.001), respectively. Severe delirium was associated with delayed functional recovery after SAVR and persistent functional impairment after TAVR at 12 months.

Conclusion: Less invasive TAVR was associated with lower incidence of delirium than SAVR. Once delirium developed, TAVR patients had more severe delirium and worse functional status trajectory than SAVR patients did.

Registration: NCT01845207.

Introduction

Delirium is a major postoperative complication after cardiac surgical procedures that develops when patients with predisposing risk factors (eg, cognitive impairment and frailty) are exposed to acute stress (eg, surgery and pain).[1] Once considered an acute and transient state, contemporary evidence supports long-term consequences of delirium after major cardiac surgery, including mortality,[2] functional decline,[3] and cognitive impairment.[4] Recently, aortic valve replacement volumes have been rising as transcatheter aortic valve replacement (TAVR) has become an established treatment of aortic stenosis (AS) in older adults at intermediate to high risk for surgical aortic valve replacement (SAVR).[5] Since TAVR is minimally invasive, with a generally shorter procedure time and no need for sternotomy or cardiopulmonary bypass, it imposes overall less physiologic stress than SAVR[6–8] and may cause less delirium and allow faster functional recovery.

Earlier studies of delirium in cardiac surgery were largely conducted in patients undergoing coronary artery bypass graft surgery.[2,3] The incidence of delirium in the literature ranges from 25% to 66% after major cardiac surgery[1,9,10] and from 5% to 45% after TAVR.[11] This variation in the delirium incidence may be driven by different assessments of delirium (eg, medical records[12] or diagnosis codes[13]). Although the association of delirium with prolonged hospitalization, nonhome discharge, and mortality after major cardiac surgery[14–16] and TAVR[10,12–14,16–19] is well established, it is less well studied how delirium is associated with functional recovery.[3,20]

We conducted a prospective cohort study to investigate the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR. We sought insight into the role of predisposing and precipitating factors in development of delirium, by examining the incidence and outcomes of delirium in SAVR and TAVR patients, who have different degrees of preoperative vulnerability and undergo procedures involving different levels of acute stress.

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