Postoperative delirium common after TAVR

By Will Boggs MD

NEW YORK (Reuters Health) - About one in 12 patients undergoing transcatheter aortic valve replacement (TAVR) will develop in-hospital postoperative delirium (IHPOD), according to a systematic review and meta-analysis.

"Delirium is a common and serious cognitive disorder following TAVR, with core features of disturbances in attention and awareness, with additional disturbances in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, perception)," Masieh Abawi of University Medical Center Utrecht in the Netherlands told Reuters Health by email.

Previous studies have found that IHPOD after TAVR is associated with prolonged hospital stay, readmission and mortality after TAVR.

Abawi and colleagues evaluated the incidence and predictors of POD after TAVR in their systematic review and meta-analysis of 31 publications involving more than 32,000 participants.

The crude incidence of IHPOD following TAVR ranged from 0% to 44.6%, with a pooled-estimate rate of 8.1%, the team reports in the Journal of the American Geriatrics Society, online October 8.

The pooled-estimate rate was considerably lower after transfemoral TAVR (7.2%) than after non-transfemoral TAVR (21.4%).

There was no significant relationship between IHPOD after TAVR and mean age, percentage of participants treated using transfemoral access, or cardiac-surgery risk score (logistic EuroSCORE).

"As it is known from the literature, >75% of the patients undergoing TAVR have new cerebral ischemic lesions on MRI," Abawi explained. "However, only 3-5% develop neurological symptoms after TAVR. Previously, we have shown that the majority of these 'silent' lesions are associated with delirium after TAVR."

"Although cerebral protection devices are shown to reduce the number and volume of these new cerebral ischemic lesions following TAVR, the impact of these devices on the incidence of delirium after TAVR are not evaluated yet," he said. "Future studies are therefore needed to evaluate whether the use of cerebral protection device during TAVR reduces the incidence of delirium after TAVR."

Dr. Peter Stachon from University Heart Center Freiburg-Bad Krozingen, in Freiburg, Germany, who recently reported risk factors and outcomes of POD after TAVR, told Reuters Health by email, "Even if we could not observe an independent increase for risk of mortality in patients with POD (only an association), POD is a severe condition associated with the possibility of longer need for mechanical ventilation, length of hospital stay, and long-term decline of cognition. Therefore, it is crucial to avoid POD."

"We analyzed our patients and could show that the minimalist approach using conscious sedation without transesophageal echocardiography resulting in a short period in ICU is an effective way to reduce the incidence of POD," said Dr. Stachon, who was not involved in the new work. "Whether cerebral protection systems during the procedure are able to reduce the incidence of POD needs to be proven."

SOURCE: https://bit.ly/2DQgXbK

J Am Geriatr Soc 2018.