1
|
Schwesinger A, Tsai LT, Lang W, Mantegazza N, Bauernschmitt R, Wilhelm MJ, Bischoff-Ferrari HA, Gagesch M. Does Comprehensive Geriatric Assessment Reduce the Incidence of Postoperative Delirium? A Quasi-experimental Study in Older Adults Undergoing Transcatheter Aortic Valve Implantation. Clin Interv Aging 2024; 19:347-355. [PMID: 38434577 PMCID: PMC10909326 DOI: 10.2147/cia.s448167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/06/2024] [Indexed: 03/05/2024] Open
Abstract
Purpose Postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) is frequent in older adults and associated with multiple negative outcomes including a higher mortality. We aimed to investigate whether a comprehensive geriatric assessment (CGA) prior to TAVI reduces the odds of POD and results in a positive change in self-care ability, intended to lay a foundation for future geriatric comanagement. Patients and methods We used a retrospective, single-center study with a quasi-experimental design enrolling patients aged 70 years and older undergoing CGA before elective TAVI, and a nonrandomized comparison group without preoperative CGA. Data on POD occurrence during the first 5 days after TAVI (primary outcome) and change in self-care ability index (SPI) between admission and discharge (secondary outcome) were collected from electronic health records and CGA data (exposure) by clinical assessment. To explore associations between (1) CGA and POD, and (2) CGA and SPI, multivariate logistic regression and linear regression models were applied adjusting for age, sex, BMI, and number of medications. Results Among 435 patients (mean age 81.0 ± 5.6 years, 43.6% women, median [IQR] SPI at baseline 40 [39, 40] points), POD incidence was 14.3% in the CGA group vs 18.8% in the non-CGA group (P 0.219). Undergoing CGA before TAVI was not associated with the odds for POD (OR: 1.15; 95%CI: 0.65-2.04) or improved SPI (P 0.073). Conclusion We observed no association of CGA prior to TAVI with POD incidence or postoperative self-care, highlighting the need for additional studies investigating the effect of POD preventive measures in older TAVI patients integrated into a comprehensive geriatric comanagement program.
Collapse
Affiliation(s)
- Anna Schwesinger
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Li-Tang Tsai
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Wei Lang
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Noemi Mantegazza
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | | | | | - Heike Annette Bischoff-Ferrari
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland
- IHU HealthAge, University Hospital Toulouse and University Toulouse III Paul Sabatier, Toulouse, France
| | - Michael Gagesch
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
- University Clinic of Aging Medicine, Zurich City Hospital, Zurich, Switzerland
| |
Collapse
|
2
|
Ko CC, Hung KC, Chang YP, Liu CC, Cheng WJ, Wu JY, Li YY, Lin TC, Sun CK. Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review. Sci Rep 2023; 13:16241. [PMID: 37758810 PMCID: PMC10533830 DOI: 10.1038/s41598-023-43548-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.
Collapse
Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Wan-Jung Cheng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yu-Yu Li
- Department of Anesthesiology, Chi Mei Medical Center, Chiali, Tainan City, Taiwan
| | - Tso-Chou Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Dachang Hospital, I-Shou University, No. 305, Dachang 1St Road, Sanmin District, Kaohsiung City, Taiwan.
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan.
| |
Collapse
|
3
|
Ma X, Chu H, Han K, Shao Q, Yu Y, Jia S, Wang D, Wang Z, Zhou Y. Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:646-660. [PMID: 36419366 DOI: 10.1111/jgs.18104] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 11/25/2022]
Abstract
AIMS To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). METHODS We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. RESULTS A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73). CONCLUSIONS POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.
Collapse
Affiliation(s)
- Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Huijun Chu
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuo Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dunliang Wang
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Takeuchi M, Suzuki H, Matsumoto Y, Kikuchi Y, Takanami K, Wagatsuma T, Sugisawa J, Tsuchiya S, Nishimiya K, Hao K, Godo S, Shindo T, Shiroto T, Takahashi J, Kumagai K, Kohzuki M, Takase K, Saiki Y, Yasuda S, Shimokawa H. Prediction of the development of delirium after transcatheter aortic valve implantation using preoperative brain perfusion SPECT. PLoS One 2022; 17:e0276447. [PMID: 36327325 PMCID: PMC9632803 DOI: 10.1371/journal.pone.0276447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives Delirium is an important prognostic factor in postoperative patients undergoing cardiovascular surgery and intervention, including transcatheter aortic valve implantation (TAVI). However, delirium after transcatheter aortic valve implantation (DAT) is difficult to predict and its pathophysiology is still unclear. We aimed to investigate whether preoperative cerebral blood flow (CBF) is associated with DAT and, if so, whether CBF measurement is useful for predicting DAT. Methods We evaluated CBF in 50 consecutive patients before TAVI (84.7±4.5 yrs., 36 females) using 99mTc ethyl cysteinate dimer single-photon emission computed tomography. Preoperative CBF of the DAT group (N = 12) was compared with that of the non-DAT group (N = 38) using whole brain voxel-wise analysis with SPM12 and region of interest-based analysis with the easy-Z score imaging system. Multivariable logistic regression analysis with the presence of DAT was used to create its prediction model. Results The whole brain analysis showed that preoperative CBF in the insula was lower in the DAT than in the non-DAT group (P<0.05, family-wise error correction). Decrease extent ratio in the insula of the DAT group (17.6±11.5%) was also greater relative to that of the non-DAT group (7.0±11.3%) in the region of interest-based analysis (P = 0.007). A model that included preoperative CBF in the insula and conventional indicators (frailty index, short physical performance battery and mini-mental state examination) showed the best predictive power for DAT (AUC 0.882). Conclusions These results suggest that preoperative CBF in the insula is associated with DAT and may be useful for its prediction.
Collapse
Affiliation(s)
- Masashi Takeuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Rehabilitation Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hideaki Suzuki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Brain Sciences, Imperial College London, London, United Kingdom
| | | | - Yoku Kikuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kentaro Takanami
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiro Wagatsuma
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Sugisawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Tsuchiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiichiro Kumagai
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masahiro Kohzuki
- Department of Rehabilitation Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- National Cerebral and Cardiovascular Center, Suita, Japan
- * E-mail:
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Graduate School of Medicine, International University of Health and Welfare, Narita, Japan
| |
Collapse
|
5
|
Stroke, Seizures, Hallucinations and Postoperative Delirium as Neurological Complications after Cardiac Surgery and Percutaneous Valve Replacement. J Cardiovasc Dev Dis 2022; 9:jcdd9110365. [PMID: 36354764 PMCID: PMC9694228 DOI: 10.3390/jcdd9110365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Neurological complications such as acute ischemic stroke or postoperative delirium are frequent after cardiac surgery or percutaneous valve replacement. This study aimed to identify corresponding risk factors. (2) Methods: 297 patients with percutaneous valve replacement or cardiac surgery were postoperatively screened for neurological complications such as delirium, stroke, seizures and hallucinations twice daily for three days. Pre- and perioperative risk factors were evaluated in a multivariate model. (3) Results: Neurological complications occurred in 43.8% (n = 130) as composed of delirium (43.43%, n = 129), stroke (2.7%, n = 8), seizures (1.35%, n = 4) and real hallucinations (3.36%, n = 10). Multiple logistic regression revealed an association of neurological complications with lower Montreal Cognitive Assessment scores (Exp(B) 2.042; 95% CI, 1.183−3.525, p = 0.010), older age (Exp(B) 1.071; 95% CI, 1.036−1.107, p < 0.001), red blood cell transfusions until postoperative day 3 (Exp(B) 1.157; 95% CI, 1.030−1.300, p = 0.014), history of heart failure (Exp(B) 1.985; 95% CI, 1.130−3.487, p = 0.017) and increased CRP levels (Exp(B) 1.004; 95% CI, 1.000−1.008, p = 0.037). (4) Conclusions: Postoperative delirium remains a frequent complication after cardiac surgery, while stroke and seizures occur rarely. A preoperative risk profile including older age, history of heart failure and cognitive impairment was identified for a complicated postoperative course. However, the impact of an intense inflammatory response must not be neglected.
Collapse
|
6
|
Dautzenberg L, van Aarle TTM, Stella PR, Emmelot-Vonk M, Weterman MA, Koek HL. The impact of frailty on adverse outcomes after transcatheter aortic valve replacement in older adults: A retrospective cohort study. Catheter Cardiovasc Interv 2022; 100:439-448. [PMID: 35830708 PMCID: PMC9545405 DOI: 10.1002/ccd.30320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/17/2022] [Accepted: 06/25/2022] [Indexed: 12/13/2022]
Abstract
Background Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement for patients who are at increased surgical risk. Consequently, frailty is common in patients undergoing TAVR. Objectives This study aims to investigate the impact of frailty on outcomes following TAVR. Methods A retrospective cohort study was conducted, including all TAVR candidates who visited the geriatric outpatient clinic for preoperative screening. Frailty status was assessed according to the Groningen Frailty Indicator. The primary outcome of the study was defined as the occurrence of postoperative complications, and this was evaluated according to the Clavien–Dindo classification. An additional analysis was performed to assess the impact of frailty on 1‐year all‐cause mortality and complications within 30 days of TAVR according to the Valve Academic Research Consortium (VARC‐2) criteria. The VARC‐2 criteria provide harmonized endpoint definitions for TAVR studies. Results In total, 431 patients with a mean age of 80.8 ± 6.2 years were included, of whom 56% were female. Frailty was present in 36% of the participants. Frailty was associated with a higher risk of the composite outcome of complications [adjusted odds ratio (OR): 1.55 (95% confidence interval, CI: 1.03–2.34)], 30‐day mortality [adjusted OR: 4.84 (95% CI: 1.62–14.49)], 3‐month mortality [adjusted OR: 2.52 (95% CI: 1.00–6.28)] and 1‐year mortality [adjusted OR: 2.96 (95% CI: 1.46–6.00)]. Conclusions Frailty is common in TAVR patients and is associated with an increased overall risk of postoperative complications, particularly mortality. Increased optimization of screening and treatment of frailty in the guidelines for valvular heart diseases is recommended.
Collapse
Affiliation(s)
- Lauren Dautzenberg
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tessa T M van Aarle
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter R Stella
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marielle Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marcel A Weterman
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Huiberdina L Koek
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
7
|
Arbabi M, Ziaei E, Amini B, Ghadimi H, Rashidi F, Shohanizad N, Moradi S, Beikmarzehei A, Hasanzadeh A, Parsaei A. Delirium risk factors in hospitalized patient: a comprehensive evaluation of underlying diseases and medications in different wards of a large Urban Hospital Center in Iran. BMC Anesthesiol 2022; 22:147. [PMID: 35578181 PMCID: PMC9109388 DOI: 10.1186/s12871-022-01690-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is a neurobehavioral syndrome, which is characterized by a fluctuation of mental status, disorientation, confusion and inappropriate behavior, and it is prevalent among hospitalized patients. Recognizing modifiable risk factors of delirium is the key point for improving our preventive strategies and restraining its devastating consequences. This study aimed to identify and investigate various factors predisposing hospitalized patients to develop delirium, focusing mostly on underlying diseases and medications. METHOD In a prospective, observational trial, we investigated 220 patients who had been admitted to the internal, emergency, surgery and hematology-oncology departments. We employed the Confusion Assessment Method (CAM) questionnaire, The Richmond Agitation Sedation Scale (RASS), the General Practitioner Assessment of Cognition (GPCOG), demographic questionnaire, patient interviews and medical records. Multivariate logistic regression models were used to analyze the predictive value of medications and underlying diseases for daily transition to delirium.; demographics were analyzed using univariate analysis to identify those independently associated with delirium. RESULTS Two hundred twenty patients were enrolled; the emergency department had the most incident delirium (31.3%), and the surgery section had the least (2.4%); delirium was significantly correlated with older ages and sleep disturbance. Among multiple underlying diseases and the medications evaluated in this study, we found that a history of dementia, neurological diseases and malignancies increases the odds of transition to delirium and the use of anticoagulants decreases the incident delirium. CONCLUSION Approximately 1 out of 10 overall patients developed delirium; It is important to evaluate underlying diseases and medications more thoroughly in hospitalized patients to assess the risk of delirium.
Collapse
Affiliation(s)
- Mohammad Arbabi
- Brain & Spinal Cord Injury Research Centre, Tehran University of Medical Sciences, Tehran, Iran.,Psychosomatic Medicine Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Ziaei
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Behnam Amini
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Hamidreza Ghadimi
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Fatemeh Rashidi
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | | | - Soroush Moradi
- Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Jalal Street, Tehran, 1411713139, Iran
| | | | | | - Amirhossein Parsaei
- Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Jalal Street, Tehran, 1411713139, Iran.
| |
Collapse
|
8
|
Wesselink EM, Abawi M, Kooistra NHM, Kappen TH, Agostoni P, Emmelot-Vonk M, Pasma W, van Klei WA, van Jaarsveld RC, van Dongen CS, Doevendans PAFM, Slooter AJC, Stella PR. Intraoperative hypotension and delirium among older adults undergoing transcatheter aortic valve replacement. J Am Geriatr Soc 2021; 69:3177-3185. [PMID: 34612514 PMCID: PMC9293424 DOI: 10.1111/jgs.17361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 01/21/2023]
Abstract
Background Postoperative delirium (POD) is a frequently observed complication after transcatheter aortic valve replacement (TAVR). The effects of intraoperative hypotension (IOH) on POD occurrence are currently unclear. Methods A retrospective observational cohort study of patients who underwent TAVR was conducted. We predefined IOH as area under the threshold (AUT) of five mean arterial blood pressures (MBP), varying from <100 to <60 mmHg. The AUT consisted of the combination of duration and depth under the MBP thresholds, expressed in mmHg*min. All MBP AUTs were computed based on the complete procedure, independent of procedural phase or duration. Results This cohort included 675 patients who underwent TAVR under general anesthesia (n = 128, 19%) or procedural sedation (n = 547, 81%). Delirium occurred mostly during the first 2 days after TAVR, and was observed in n = 93 (14%) cases. Furthermore, 674, 672, 663, 630, and 518 patients had at least 1 min intraoperative MBP <100, <90, <80, <70, and <60 mmHg, respectively. Patients who developed POD had higher AUT based on all five MBP thresholds during TAVR. The penalized adjusted odds ratio varied between 1.08 (99% confidence interval [CI] 0.74–1.56) for the AUT based on MBP < 100 mmHg and OR 1.06 (99% CI 0.88–1.28) for the AUT based on MBP < 60 mmHg. Conclusions Intraoperative hypotension is frequently observed during TAVR, but not independently associated with POD after TAVR. Other potential factors than intraoperative hypotension may explain the occurrence of delirium after TAVR.
Collapse
Affiliation(s)
- Esther M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Masieh Abawi
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nynke H M Kooistra
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pierfrancesco Agostoni
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Marielle Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wietze Pasma
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Romy C van Jaarsveld
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charlotte S van Dongen
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter A F M Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
9
|
van der Wulp K, van Wely MH, Schoon Y, Vart P, Olde Rikkert MG, Morshuis WJ, van Royen N, Verkroost MW, Gehlmann HR, Van Garsse LA, Kievit PC. Geriatric assessment in the prediction of delirium and long-term survival after transcatheter aortic valve implantation. J Thorac Cardiovasc Surg 2021; 161:2095-2102.e3. [DOI: 10.1016/j.jtcvs.2020.02.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/07/2020] [Accepted: 02/14/2020] [Indexed: 12/15/2022]
|
10
|
Mauri V, Reuter K, Körber MI, Wienemann H, Lee S, Eghbalzadeh K, Kuhn E, Baldus S, Kelm M, Nickenig G, Veulemans V, Jansen F, Adam M, Rudolph TK. Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement. Front Cardiovasc Med 2021; 8:645724. [PMID: 33842564 PMCID: PMC8032857 DOI: 10.3389/fcvm.2021.645724] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test. Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030]. Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.
Collapse
Affiliation(s)
- Victor Mauri
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Kevin Reuter
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Maria I Körber
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Samuel Lee
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Faculty of Medicine, Heart Centre, University of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Faculty of Medicine, Heart Centre, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,CARID (Cardiovascular Research Institute Düsseldorf), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Georg Nickenig
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Felix Jansen
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Matti Adam
- Department of Cardiology, Faculty of Medicine, Heart Center, University of Cologne, Cologne, Germany
| | - Tanja K Rudolph
- General and Interventional Cardiology, Heart and Diabetes Centre Nordrhein-Westfalen, Bad Oeynhausen, Germany.,Medical Faculty, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|
11
|
Humbert M, Büla CJ, Muller O, Krief H, Monney P. Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis. BMC Geriatr 2021; 21:153. [PMID: 33653285 PMCID: PMC7927377 DOI: 10.1186/s12877-021-02100-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/22/2021] [Indexed: 12/14/2022] Open
Abstract
Background Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR). Methods Patients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR. Results Delirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2–15.1, p = .025) and 16.5 (95%CI 2.0–138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [− 3.03–0.80], p = .248). Conclusions Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02100-5.
Collapse
Affiliation(s)
- Marc Humbert
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland.
| | - Christophe J Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Hélène Krief
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| |
Collapse
|
12
|
Ooms JF, Van Wiechen MP, Hokken TW, Goudzwaard J, De Ronde-Tillmans MJ, Daemen J, Mattace-Raso F, De Jaegere PP, Van Mieghem NM. Simplified Trans-Axillary Aortic Valve Replacement Under Local Anesthesia - A Single-Center Early Experience. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:7-13. [PMID: 33281073 DOI: 10.1016/j.carrev.2020.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The axillary artery is an alternative route for patients with comorbidities and unfavorable femoral arteries who need transcatheter aortic valve replacement (TAVR). Simplified trans-axillary transcatheter aortic valve replacement (TAx-TAVR) implies a completely percutaneous approach under local anesthesia and arteriotomy closure with vascular closure techniques. Herein, we report on early experience with simplified TAx-TAVR under local anesthesia. METHODS We enrolled all consecutive patients who underwent simplified TAx-TAVR in our center. Main study parameter was the incidence of axillary access related major vascular complications within 30 days. Secondary parameters included a composite early safety endpoint, axillary access-site related vascular/bleeding complications and short-term mortality. Post TAVR axillary stent patency was evaluated during follow-up by CT-analysis. RESULTS Between July 2018 and April 2020, Tax-TAVR was attempted in 35 patients with a mean age of 79 years. Local anesthesia and conscious sedation were used in 91.4% (n = 32) and 8.6% (n = 3) respectively. A covered stent was needed for complete axillary hemostasis in 44.1% (n = 15). Device success was achieved in 91.2% (n = 31/34). The 30-day axillary artery major vascular and ≥major bleeding complication rates were 14% (n = 5) and 11% (n = 4). The early safety endpoint was reached in 22.9% (n = 8). Mortality rates at 30 days and six months were 2.9% and 11.6%. Computed tomography (CT) confirmed axillary stent patency during follow-up in 82% (n = 9/11). CONCLUSIONS In patients with high/prohibitive surgical risk and unsuitable femoral access, simplified TAx-TAVR under local anesthesia offers a valuable alternative for transfemoral TAVR but requires advanced access site management techniques including covered stents. Our data suggest an unmet clinical need for dedicated TAx closure devices.
Collapse
Affiliation(s)
- Joris F Ooms
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maarten P Van Wiechen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Thijmen W Hokken
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeannette Goudzwaard
- Section of Geriatrics, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marjo J De Ronde-Tillmans
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Francesco Mattace-Raso
- Section of Geriatrics, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter P De Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
| |
Collapse
|
13
|
Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 406] [Impact Index Per Article: 101.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
Collapse
Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| |
Collapse
|
14
|
Delirium After TAVR. JACC Cardiovasc Interv 2020; 13:2453-2466. [DOI: 10.1016/j.jcin.2020.07.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
|
15
|
Beishuizen SJ, Festen S, Loonstra YE, van der Werf HW, de Rooij SE, van Munster BC. Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study. Geriatr Gerontol Int 2020; 20:1202-1207. [PMID: 33098368 PMCID: PMC7756254 DOI: 10.1111/ggi.14064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 09/08/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
AIM Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI. METHODS This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up. RESULTS The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome. CONCLUSION In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.
Collapse
Affiliation(s)
- Sara J Beishuizen
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Suzanne Festen
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Yvette E Loonstra
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Hindrik W van der Werf
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Sophia E de Rooij
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands.,Medical School Twente, Medical Spectrum Twente, Enschede, the Netherlands
| | - Barbara C van Munster
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
16
|
Maier A, Hammerich B, Humburger F, Brieschal T, Heidt T, Bothe W, Schröfel H, Kaier K, Zehender M, Reinöhl J, Bode C, von zur Mühlen C, Stachon P. A logistic regression analysis comparing minimalistic approach and intubation anaesthesia in patients undergoing transfemoral transcatheter aortic valve replacement. PLoS One 2020; 15:e0227345. [PMID: 32023258 PMCID: PMC7001937 DOI: 10.1371/journal.pone.0227345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/06/2019] [Indexed: 12/26/2022] Open
Abstract
Aims Patients with postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR) are ventilated and hospitalized longer and suffer increased in-hospital mortality. This study hypothesized that a minimalistic approach with conscious sedation during transfemoral aortic valve replacement (TF-AVR) protects against delirium, time of mechanical ventilation, and increased length of stay in intensive care unit (ICU) compared to intubation anaesthesia. Methods and results 308 patients which underwent TF-AVR in our centre between 01/2013 and 08/2017 were retrospectively evaluated regarding postoperative delirium, time of mechanical ventilation, and days in ICU. TF-AVR was performed with intubation anaesthesia in 245 patients and with conscious sedation in 63. The operative risk estimated by the logEUROScore was similar in both groups (intubation: 13.28 +/-9.06%, conscious sedation: 12.24 +/-6.77%, p = 0.395). In the conscious sedation group procedure duration was shorter (0.61 +/-0.91h vs. 1.75 +/-0.96h, p<0.001). The risk for intraprocedural complications was not influenced by the anaesthesia method (OR conscious sedation instead of intubation 1.66, p = 0.117), but days on ICU (-2.21 days, p<0.0001) and minutes of mechanical ventilation (-531.2 min, p < 0.0001) were reduced. Furthermore, the risk of POD was decreased when TF-AVR was performed under conscious sedation (6.35% vs. 18.18%, OR 0.29, p = 0.021). Conclusions Time of mechanical ventilation, risk of POD, and days on ICU were substantially reduced in patients who underwent TF-AVR under conscious sedation. Our data suggest that TF-AVR with conscious sedation is safe with a beneficial postoperative course in clinical practice, and should be considered the favoured approach.
Collapse
Affiliation(s)
- Alexander Maier
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Benedikt Hammerich
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Frank Humburger
- Department of Anaesthesiology and Critical Care, University Hospital Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Brieschal
- Department of Anaesthesiology and Critical Care, University Hospital Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Timo Heidt
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Wolfgang Bothe
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Faculty of Medicine and Medical Centre-University of Freiburg, Institute of Medical Biometry and Statistics, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Jochen Reinöhl
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
- Edwards LifeScience, Nyon, Switzerland
| | - Christoph Bode
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
- * E-mail:
| |
Collapse
|
17
|
Stragier H, Dubois C, Verbrugghe P, Jacobs S, Adriaenssens T, Rex S. General Anesthesia Versus Monitored Anesthesia Care for Transfemoral Transcatheter Aortic Valve Implantation: A Retrospective Study in a Single Belgian Referral Center. J Cardiothorac Vasc Anesth 2019; 33:3283-3291. [DOI: 10.1053/j.jvca.2019.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/11/2022]
|
18
|
Abstract
Evidence in transcatheter aortic valve replacement (TAVR) has accumulated rapidly over the last few years and its application to clinical decision making are becoming more important. In this review, we discuss the advances in TAVR for patient selection, expanding indications, complications, and emerging technologies.
Collapse
|
19
|
Complications After Transcatheter Aortic Valve Implantation: an Updated Umbrella Review. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00202-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
20
|
van der Wulp K, van Wely M, van Heijningen L, van Bakel B, Schoon Y, Verkroost M, Gehlmann H, Van Garsse L, Vart P, Kievit P, Rikkert MO, Morshuis W, van Royen N. Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival. J Am Geriatr Soc 2019; 67:2325-2330. [PMID: 31342524 PMCID: PMC6899857 DOI: 10.1111/jgs.16087] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival. DESIGN Prospective cohort study. SETTING Academic medical center. PARTICIPANTS A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017. MEASUREMENTS Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively). RESULTS POD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm2 (OR = 2.39; 95% CI = 1.53‐3.74). CONCLUSION One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325–2330, 2019
Collapse
Affiliation(s)
- Kees van der Wulp
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marleen van Wely
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lars van Heijningen
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bram van Bakel
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Schoon
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Verkroost
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leen Van Garsse
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Priya Vart
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Kievit
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Olde Rikkert
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim Morshuis
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
21
|
Delirium is associated with higher mortality in transcatheter aortic valve replacement: systemic review and meta-analysis. Cardiovasc Interv Ther 2019; 35:168-176. [DOI: 10.1007/s12928-019-00592-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022]
|
22
|
Shi SM, Sung M, Afilalo J, Lipsitz LA, Kim CA, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Lee J, Marcantonio ER, Kim DH. Delirium Incidence and Functional Outcomes After Transcatheter and Surgical Aortic Valve Replacement. J Am Geriatr Soc 2019; 67:1393-1401. [PMID: 30882905 DOI: 10.1111/jgs.15867] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 12/19/2022]
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.
Collapse
Affiliation(s)
- Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Minhee Sung
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Lewis A Lipsitz
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Caroline A Kim
- Division of Hospital Medicine, South Shore Hospital, Weymouth, Massachusetts
| | - Jeffrey J Popma
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger J Laham
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kimberly Guibone
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jung Lee
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|