Adult: Aortic Valve
The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement

Accepted for the 100th Annual Meeting of The American Association for Thoracic Surgery.
https://doi.org/10.1016/j.jtcvs.2022.01.053Get rights and content

Abstract

Objective

The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.

Methods

Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.

Results

By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference −3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference −2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).

Conclusions

Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.

Section snippets

Study Population

The study population included 383 patients enrolled in a randomized trial evaluating embolic protection devices in SAVR, conducted by CTSN.8 Patients were randomly assigned (1:1:1 ratio) to receive an intra-aortic filtration embolic protection device (EMBOL-X, Edwards Lifesciences), a suction-based extraction embolic protection device (CardioGard; CardioGard, Inc), or a standard aortic cannula. The primary aim of the trial was to establish the efficacy of 2 mechanistically different embolic

Patient Characteristics

Table 1 depicts baseline and operative characteristics of patients stratified by whether or not they experienced stroke or delirium (see Table E1 in Appendix E1 for characteristics of all trial patients). By postoperative day 7, 6.6% (25/379) of patients experienced clinically apparent stroke and 28.5% (103/362) showed evidence of delirium. The median NIHSS at diagnosis of stroke was 5 (IQR, 2-14). Of those who presented evidence of a clinically apparent stroke, 11 were mild (NIHSS 0-4), 9

Discussion

The CTSN neuroprotection trial, which found that both stroke and delirium were common in patients who underwent SAVR, is one of the largest randomized trials of embolic protection devices that included repeated neurologic examinations and a postoperative MRI.8 By day 7 after surgery, 7% of patients experienced clinically apparent stroke when assessed with active surveillance. Patients who experienced these events had longer hospitalizations, were almost 6 times more likely to be disabled, 5

Conclusions

There is a high risk of stroke and delirium after SAVR when ascertained by active surveillance, and such events have profound clinical consequences. Patients who experience these complications have increased disability, depression, and cognitive decline, along with reduced quality of life. These findings support the use of serial examinations and MRI in neuroprotection studies of surgical patients, as advocated in a recent Neurologic Academic Research Consortium consensus statement on

Cited by (3)

The neuroprotection trial was supported by a cooperative agreement (U01 HL088942) funded by the National Heart Lung and Blood Institute and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health, Bethesda, Md, and the Canadian Institutes for Health Research, Ottawa, Ontario, Canada. The embolic protection device companies provided no financial support but did provide training in device use.

ClinicalTrials.gov Identifier: NCT02389894.

The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; National Institutes of Health; or the United States Department of Health and Human Services.

1

Cardiothoracic Surgical Trials Network (CTSN) Investigators (see Appendix E1).

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