Impact of delirium in acute cardiac care unit after transcatheter aortic valve replacement

https://doi.org/10.1016/j.ijcard.2021.01.053Get rights and content

Highlights

  • Delirium occurs in about one quarter of patients undergoing TAVR.

  • It is associated with a longer hospital stay and poorer mid-term outcomes.

  • Several independent factors identify patients at high risk of developing delirium.

Abstract

Background

Delirium is a cognitive disorder that commonly occurs during hospitalization in acute cardiac care units (ACCU), but its effect after transcatheter aortic valve replacement (TAVR) has not been well evaluated. The objective of this study is to determine the incidence, predictive factors and prognostic impact of delirium following TAVR.

Methods

A total of 501 consecutive patients admitted to an ACCU after TAVR were included. The Confusion Assessment Method was used to evaluate delirium during ACCU stay. Risk factors, preventive pharmacological treatment, peri-procedural characteristics and complications were assessed. Clinical events were recorded with a median follow-up of 24 months.

Results

The incidence of delirium after TAVR was 22.0% (n = 110). Previous cognitive impairment (OR 4.17; 95% CI 1.11–15.71; p = 0.035), peripheral arterial disease (OR 4.54; 95% CI 1.79–11.54; p = 0.001), the use of general anaesthesia (OR 2.55; 95% CI 1.32–4.90; p = 0.005), and prolonged mechanical ventilation (OR 18.86; 95% CI 1.85–192.58; p = 0.013) were significantly associated with the development of delirium. Patients with delirium had a greater hospital length of stay (7.5 [5.5–13.5] vs 5.6 [4.6–8.2] days, mean difference − 3.49; 95% CI -5.45 to −1.52; p < 0.001), and higher in-hospital (OR 2.68; 95% CI 1.02–6.99; p = 0.045), 1-year (HR 2.09; 95% CI 1.13–3.87; p = 0.018) and 2-year mortality (HR 1.94; 95% CI 1.12–3.34; p = 0.017).

Conclusions

Delirium is a frequent complication in patients admitted to ACCU after TAVR, and is associated with prolonged hospital stay and higher in-hospital and mid-term mortality.

Introduction

Delirium is a neuropsychiatric syndrome of acute onset characterized by a fluctuating mental state. Its effect on mortality, length of hospital stay and readmissions, residual cognitive impairment and institutionalization has been extensively described [[1], [2], [3], [4], [5]]. The reported incidence of this disorder varies widely depending on patient characteristics, type of acute illness or intervention, and evaluation method [[2], [3], [4], [5], [6]]. Patients undergoing major surgery, particularly cardiothoracic surgery, have the highest incidence of delirium [6,7]. Specifically, the incidence of postoperative delirium after surgical aortic valve replacement has been reported to be as high as 33% [3].

Transcatheter aortic valve replacement (TAVR) is a rapidly evolving technology, becoming the standard treatment for intermediate and high-risk patients with severe aortic stenosis as an alternative to surgery [8,9]. The incidence of postoperative delirium in patients with TAVR compared to surgical replacement may be considerably lower, since many of the traditional factors associated with the development of delirium after conventional surgery are minimized or eliminated in this less invasive technique [10]. However, its incidence (ranging from 5% to 30%) [1,3,[11], [12], [13], [14]] substantially increases in the elderly, which are the typical TAVR population. Unlike the growing literature on delirium in patients of general medical and surgical intensive care units [4,5], evidence regarding delirium in patients of acute cardiac care units (ACCU) after TAVR is still scarce. The objective of this study was to determine the incidence, predictive factors, and prognostic value of delirium in patients admitted to an ACCU after transfemoral TAVR.

Section snippets

Study population

Consecutive patients from a single centre who were admitted to an ACCU after transfemoral TAVR from February 2007 to January 2018 were included. In all cases, TAVR was performed to treat symptomatic severe aortic stenosis, defined as an aortic valve area of <1 cm2, mean gradient >40 mmHg or a maximum velocity >4.0 m/s. All patients were offered TAVR after discussion and consensus in a multidisciplinary heart team meeting. Patients who died within the first 24 h after implantation, and those

Results

Among 529 patients initially screened for inclusion, 501 were included in the final study after applying exclusion criteria (10 patients died in the first 24 h, 9 patients had a severe psychiatric disorder, and 9 patients had no information regarding delirium [Supplementary material Table 1]). The average age was 82.9 ± 5.8 years, and 289 patients (57.7%) were women. During ACCU admission, delirium was diagnosed in 110 patients (22.0%), of which 87 cases (79.1%) occurred within the first 24 h

Discussion

Delirium is a frequent problem during hospitalization, especially in the elderly, although its incidence and prognostic consequences in patients admitted to an ACCU have not been frequently described. Our study is one of the first to describe both the incidence and risk factors associated with delirium specifically in patients admitted to an ACCU after TAVR. The incidence observed in this study is consistent with other similar studies, which report rates of up to 29% [1,3,[11], [12], [13], [14]

Conclusions

Delirium is a common complication in elderly people admitted to acute cardiac care units after implantation of transfemoral aortic valve prosthesis, with a notable impact on short and mid-term prognosis. Further investigations regarding preventive strategies and early recognition of delirium are necessary in order to modify its effect on clinical outcomes.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

Dr. Nombela-Franco has served as a proctor for Abbott. All other authors have no relationships to disclose relevant to the contents of this paper.

Acknowledgements

The authors thank Dra. Maria Jose Perez Vizcaino from Hospital Clínico San Carlos, Madrid, Spain for her support in the management of the TAVR and CCU databases.

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