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Post-TAVR delirium more common with nontransfemoral vs. transfemoral access
Only one in eight patients who undergo transcatheter aortic valve replacement experience postoperative delirium, with a fivefold higher rate seen with nontransfemoral transcatheter aortic valve replacement, according to results of a new study.
Researchers for the retrospective, observational, single-center study identified 268 consecutive patients (mean age, 80 years; 46% men) who underwent TAVR at the University Medical Center Utrecht, the Netherlands, for severe native aortic stenosis between November 2011 and December 2014.
The primary outcome was defined as the occurrence of delirium at any point during postoperative hospital stay. A delirium observational score was used when delirium was suspected, and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) was used to establish a definitive diagnosis.
The overall incidence of postoperative delirium was 13.4% (n = 36). Preoperatively, patients with postoperative delirium vs. non-postoperative delirium had disparities in the rates of carotid disease (33% vs. 9%; P < .001) peripheral artery disease (50% vs. 9%; P < .001) and current smoking (22% vs. 18%; P = .013).
Patients who experienced postoperative delirium were more likely to have had the following procedural factors: nontransfemoral access (50% vs. 10%; P < .001), use of general anesthesia (50% vs. 15%; P < .001) and longer duration of procedure (140 minutes vs. 124 minutes; P = .014).
Among the 36 cases of postoperative delirium, 18 were related to postprocedural complications, including major vascular complications/bleeding (n = 4), stroke (n = 3), acute kidney injury (n = 3), atrial fibrillation (n = 4) and infectious diseases (n = 4). The most common time point for postoperative delirium diagnosis was on day 2 after TAVR (interquartile range [IQR], 1-5 days) and was correlated with increased length of hospital stay independent of complications.
In uncomplicated TAVR, hospital length of stay was 6 days (IQR, 5-10 days) with postoperative delirium vs. 5 days (IQR, 4-5 days) without postoperative delirium; in complicated TAVR, length of stay was 9 days (IQR, 8-15 days) with postoperative delirium vs. 6 days (IQR, 5-9 days) without postoperative delirium; P < .001).
Factors deemed predictive of postoperative delirium included nontransfemoral access (OR = 7.74; 95% CI, 3.26-18.1), current smoking (OR = 3.99; 95% CI, 1.25-12.8), carotid artery disease (OR = 3.88; 95% CI, 1.5-10.1), AF (OR = 2.74; 95% CI, 1.17-6.39) and age (OR = 1.08; 95% CI, 1-1.17 per additional year of age). Postoperative delirium continued to be predictive of death after 16 months (IQR, 6-27 months) in patients who underwent transfemoral TAVR vs. nontransfemoral TAVR (HR = 2.81; 95% CI, 1.16-6.83 vs. HR = 0.43; 95% CI, 0.1-1.76), independent of age, sex, logistic EuroSCORE and incidence of complications.
The researchers noted that the development of postoperative delirium in TAVR appears to depend on various factors, particularly procedural access, with a fivefold higher rate in nontransfemoral procedures.
“The predictors identified in this study can aid the identification of TAVR patients who are at higher risk for developing [postoperative delirium] and who will benefit most from intensified surveillance and targeted prevention,” the researchers wrote. “Future large prospective studies are needed to confirm these first findings on [postoperative delirium] after TAVR.” – by Jennifer Byrne