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Clinical Research in Cardiology

, Volume 107, Issue 9, pp 756–762 | Cite as

Risk factors and outcome of postoperative delirium after transcatheter aortic valve replacement

  • Peter Stachon
  • Klaus Kaier
  • Andreas Zirlik
  • Jochen Reinöhl
  • Timo Heidt
  • Wolfgang Bothe
  • Philip Hehn
  • Manfred Zehender
  • Christoph Bode
  • Constantin von zur Mühlen
Original Paper

Abstract

Background

POD is associated with a worse postoperative course in patients after cardiac surgery, but its incidence and effects after TAVR are not well-understood. The aim of the present study was to analyze incidence, risk factors, and in-hospital outcomes of postoperative delirium (POD) after transfemoral (TF-AVR) and transapical (TA-AVR) transcatheter aortic valve replacement (TAVR) in a nationwide cohort.

Methods and results

Administrative data on all patients undergoing isolated TAVR in Germany in 2014 were analyzed. 9038 TF-AVR and 2522 TA-AVR procedures were performed. POD incidence was 7% after TF-AVR and 12% after TA-AVR. Atrial fibrillation (TF: OR 1.35, p < 0.001; TA: OR 1.53, p = 0.001) and NYHA III/IV (TF: OR 1.23, p = 0.017, TA: OR 1.51, p = 0.001) were independent risk factors for POD. Dementia was a risk factor only in TF-AVR (OR 3.04, p < 0.001). Female sex was protective (TF: OR 0.56, p < 0.001, TA: OR 0.51, p < 0.001). We found the occurrence of POD to be associated with more postoperative complications such as stroke and bleeding. Consequently, patients with POD were ventilated and hospitalized longer and suffered an increased risk of in-hospital mortality (unadjusted OR TF: 1.83, p = 0.001, TA: 1.82, p = 0.01). After adjusting for postoperative events and comorbidities, POD’s effect on in-hospital mortality disappeared. In contrast, stroke and bleeding remained independent predictors for mortality irrespective of POD.

Conclusions

Patients with POD after TAVR are at increased risk for in-hospital mortality. However, after adjusting for postoperative events and comorbidities, stroke and bleeding, but not POD, are independent mortality predictors.

Keywords

Transcatheter aortic valve replacement (TAVR) Postoperative delirium In-hospital mortality Outcome 

Abbreviations

CABG

Coronary artery bypass graft

CAD

Coronary artery disease

ICD

International statistical classification of diseases

OPS

German procedure classification system

NYHA

New York Heart Association-heart failure score

PAD

Peripheral artery disease

POD

Postoperative delirium

TA-AVR

Transapical aortic valve replacement

TF-AVR

Transfemoral aortic valve replacement

TAVR

Transcatheter aortic valve replacement

Notes

Acknowledgements

We thank Angelika Gerlach and Marion Rüdiger for their excellent assistance in the acquisition of the data. Furthermore, we would also like to thank the staff of the Research Data Centers of the Federal Bureau of Statistics and the statistical offices of the federal states for providing the data and the technical support during the analysis.

Funding

The study was supported by internal funding of the University Heart Center Freiburg.

Compliance with ethical standards

Conflict of interest

JR works as a proctor for Edwards Lifesciences and Direct Flow Medical. All the other authors declare no conflicts of interest.

References

  1. 1.
    Koster S, Hensens AG, van der Palen J (2009) The long-term cognitive and functional outcomes of postoperative delirium after cardiac surgery. Ann Thorac Surg 87:1469–1474CrossRefPubMedGoogle Scholar
  2. 2.
    McKhann GM, Grega MA, Borowicz LM Jr et al (2002) Encephalopathy and stroke after coronary artery bypass grafting: incidence, consequences, and prediction. Arch Neurol 59:1422–1428PubMedGoogle Scholar
  3. 3.
    Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK (2008) One-year health care costs associated with delirium in the elderly population. Arch Intern Med 168:27–32CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Fong TG, Jones RN, Shi P et al (2009) Delirium accelerates cognitive decline in Alzheimer disease. Neurology 72:1570–1575CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Fong TG, Jones RN, Marcantonio ER et al (2012) Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Intern Med 156:848–856, W296CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Gross AL, Jones RN, Habtemariam DA et al (2012) Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med 172:1324–1331CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Veliz-Reissmuller G, Aguero Torres H, van der Linden J, Lindblom D, Eriksdotter Jonhagen M (2007) Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery. Aging Clin Exp Res 19:172–177CrossRefPubMedGoogle Scholar
  8. 8.
    Inouye SK, Westendorp RG, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922CrossRefPubMedGoogle Scholar
  9. 9.
    Leon MB, Smith CR, Mack M et al (2010) Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 363:1597 – 607CrossRefPubMedGoogle Scholar
  10. 10.
    Adams DH, Popma JJ, Reardon MJ (2014) Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 371:967–968CrossRefPubMedGoogle Scholar
  11. 11.
    Leon MB, Smith CR, Mack MJ et al (2016) Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 374:1609–1620CrossRefPubMedGoogle Scholar
  12. 12.
    Bleiziffer S, Bosmans J, Brecker S et al (2017) Insights on mid-term TAVR performance: 3-year clinical and echocardiographic results from the CoreValve ADVANCE study. Clin Res Cardiol 106:784–795CrossRefPubMedGoogle Scholar
  13. 13.
    Reinohl J, Reinecke H, Zehender M (2016) Transcatheter aortic-valve replacement in clinical practice. N Engl J Med 374:1691–1692PubMedGoogle Scholar
  14. 14.
    Reinohl J, Psyrakis D, Kaier K et al (2016) Aortic root volume is associated with contained rupture of the aortic annulus in balloon-expandable transcatheter aortic valve replacement. Catheter Cardiovasc Interv 87:807–817CrossRefPubMedGoogle Scholar
  15. 15.
    Bucerius J, Gummert JF, Borger MA et al (2004) Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg 127:57–64CrossRefPubMedGoogle Scholar
  16. 16.
    Durand E, Borz B, Godin M et al (2012) Transfemoral aortic valve replacement with the Edwards SAPIEN and Edwards SAPIEN XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: feasibility and 30-day outcomes. JACC Cardiovasc Interv 5:461–467CrossRefPubMedGoogle Scholar
  17. 17.
    Durand E, Eltchaninoff H, Canville A et al (2015) Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation with the Edwards SAPIEN-XT prosthesis. Am J Cardiol 115:1116–1122CrossRefPubMedGoogle Scholar
  18. 18.
    Abawi M, Nijhoff F, Agostoni P et al (2016) Incidence, predictive factors, and effect of delirium after transcatheter aortic valve replacement. JACC Cardiovasc Interv 9:160–168CrossRefPubMedGoogle Scholar
  19. 19.
    Tse L, Bowering JB, Schwarz SK, Moore RL, Burns KD, Barr AM (2015) Postoperative delirium following transcatheter aortic valve implantation: a historical cohort study. Can J Anaesth 62:22–30CrossRefPubMedGoogle Scholar
  20. 20.
    Maniar HS, Lindman BR, Escallier K et al (2016) Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality. J Thorac Cardiovasc Surg 151:815–823e1-2CrossRefPubMedGoogle Scholar
  21. 21.
    Reinohl J, Kaier K, Reinecke H et al (2015) Effect of availability of transcatheter aortic-valve replacement on clinical practice. N Engl J Med 373:2438–2447CrossRefPubMedGoogle Scholar
  22. 22.
    Reinohl J, Kaier K, Reinecke H et al (2016) Transcatheter aortic valve replacement: the new standard in patients with previous coronary bypass grafting? JACC Cardiovasc Interv 9:2137–2143CrossRefPubMedGoogle Scholar
  23. 23.
    Abawi M, Nijhoff F, Agostoni P et al (2016) TCT-722 clinical effect of new cerebral ischemic lesions on the occurrence of postoperative delirium after transcatheter aortic valve implantation. J Am Coll Cardiol 68:B292CrossRefGoogle Scholar
  24. 24.
    Babaliaros V, Devireddy C, Lerakis S et al (2014) Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis. JACC Cardiovasc Interv 7:898–904CrossRefPubMedGoogle Scholar
  25. 25.
    Eichler S, Salzwedel A, Harnath A et al (2018) Nutrition and mobility predict all-cause mortality in patients 12 months after transcatheter aortic valve implantation. Clin Res Cardiol 107:304–311CrossRefPubMedGoogle Scholar
  26. 26.
    Norkiene I, Ringaitiene D, Misiuriene I et al (2007) Incidence and precipitating factors of delirium after coronary artery bypass grafting. Scand Cardiovasc J 41:180–185CrossRefPubMedGoogle Scholar
  27. 27.
    Kazmierski J, Kowman M, Banach M et al (2006) Preoperative predictors of delirium after cardiac surgery: a preliminary study. Gener Hosp Psychiatry 28:536–538CrossRefGoogle Scholar
  28. 28.
    Smith CD, Grami P (2016) Feasibility and effectiveness of a delirium prevention bundle in critically ill patients. Am J Crit Care 26:19–27CrossRefPubMedGoogle Scholar
  29. 29.
    Parente D, Luis C, Veiga D, Silva H, Abelha F (2013) Congestive heart failure as a determinant of postoperative delirium. Port J Cardiol 32:665–671CrossRefGoogle Scholar
  30. 30.
    Giustino G, Sorrentino S, Mehran R, Faggioni M, Dangas G (2017) Cerebral embolic protection during TAVR: a clinical event meta-analysis. J Am Coll Cardiol 69:465–466CrossRefPubMedGoogle Scholar
  31. 31.
    van der Zanden V, Beishuizen SJ, Scholtens RM, de Jonghe A, de Rooij SE, van Munster BC (2016) The effects of blood transfusion on delirium incidence. J Am Med Dir Assoc 17:748–753CrossRefPubMedGoogle Scholar
  32. 32.
    Stransky M, Schmidt C, Ganslmeier P et al (2011) Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation. J Cardiothorac Vasc Anesth 25:968–974CrossRefPubMedGoogle Scholar
  33. 33.
    Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA (2010) Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 304:443–451CrossRefPubMedGoogle Scholar
  34. 34.
    Mollmann H, Bestehorn K, Bestehorn M et al (2016) In-hospital outcome of transcatheter vs. surgical aortic valve replacement in patients with aortic valve stenosis: complete dataset of patients treated in 2013 in Germany. Clin Res Cardiol 105:553–559CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Peter Stachon
    • 1
  • Klaus Kaier
    • 2
  • Andreas Zirlik
    • 1
  • Jochen Reinöhl
    • 1
  • Timo Heidt
    • 1
  • Wolfgang Bothe
    • 3
  • Philip Hehn
    • 2
  • Manfred Zehender
    • 1
  • Christoph Bode
    • 1
  • Constantin von zur Mühlen
    • 1
  1. 1.University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical FacultyUniversity of FreiburgFreiburgGermany
  2. 2.Faculty of Medicine and Medical Center-University of FreiburgInstitute of Medical Biometry and StatisticsFreiburgGermany
  3. 3.University Heart Center Freiburg, Department of Cardiovascular Surgery, Medical FacultyUniversity of FreiburgFreiburgGermany

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