Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation.
ABSTRACT: BACKGROUND:delirium is an event leading to negative health outcomes and increased mortality in patients. The aim of this study is to investigate the incidence, determinants and consequences of post-operative delirium (POD) in older patients undergoing transcatheter aortic valve implantation (TAVI). METHODS:The TAVI Care and Cure program is a prospective, observational registry in patients referred for TAVI at Erasmus University Medical Centre. The presence of delirium was evaluated by daily clinical assessment by a geriatrician pre- and up to 3 days post-TAVI. Mortality data were obtained from the Dutch Civil Registry. RESULTS:A total of 543 patients underwent TAVI between January 2014 and December 2017. Overall, the incidence of POD was 14% (75/543 patients) but declined from 18% in 2014 to 7% in 2017 (P =?0.009). Patients who developed POD were older (81.9?±?5.8 versus 78.6?±?8.3 years, P
Project description: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.
Project description:OBJECTIVES:To determine whether an association exists between delirium and length of time indwelling urine catheters (IUC) are used in octogenarian patients treated with surgical aortic valve treatment (SAVR) or transcatheter aortic valve implantation (TAVI). DESIGN:Prospective cohort study. SETTING:Tertiary university hospital covering the western region of Norway. PARTICIPANTS:Octogenarian patients undergoing elective SAVR or TAVI and willing to participate in the study were eligible. Patients unable to speak Norwegian were excluded. Between 2011 and 2013, 143 consecutive patients were included, and data from 136 of them are presented. PRIMARY OUTCOME:Delirium. RESULTS:Logistic regression analysis shows that lower cognitive function was positively associated with delirium (OR 0.86, CI 0.74 to 0.99, p=0.047). Besides, the interaction term in the model shows that IUC use and delirium differed between SAVR and TAVI patients (p=0.04). The difference corresponded to a weaker association between hours of IUC use and delirium for SAVR (OR 1.01, CI: 0.99 to 1.03, p=0.54) compared with that for TAVI (OR 1.04, CI: 1.01 to 1.08, p=0.004). CONCLUSIONS:The association between IUC use and delirium is stronger for octogenarian patients treated with TAVI than for patients who received SAVR. Our results revealed a previously unknown association between the number of hours an IUC is used and postoperative delirium in octogenarian patients treated with TAVI.
Project description:AIMS:Systemic inflammatory response, identified by increased total leucocyte counts, was shown to be a strong predictor of mortality after transcatheter aortic valve implantation (TAVI). Yet the mechanisms of inflammation-associated poor outcome after TAVI are unclear. Therefore, the present study aimed at investigating individual inflammatory signatures and functional heterogeneity of circulating myeloid and T-lymphocyte subsets and their impact on 1 year survival in a single-centre cohort of patients with severe aortic stenosis undergoing TAVI. METHODS AND RESULTS:One hundred twenty-nine consecutive patients with severe symptomatic aortic stenosis admitted for transfemoral TAVI were included. Blood samples were obtained at baseline, immediately after, and 24 h and 3 days after TAVI, and these were analysed for inflammatory and cardiac biomarkers. Myeloid and T-lymphocyte subsets were measured using flow cytometry. The inflammatory parameters were first analysed as continuous variables; and in case of association with outcome and area under receiver operating characteristic (ROC) curve (AUC) ? 0.6, the values were dichotomized using optimal cut-off points. Several baseline inflammatory parameters, including high-sensitivity C-reactive protein (hsCRP; HR = 1.37, 95% CI: 1.15-1.63; P < 0.0001) and IL-6 (HR = 1.02, 95% CI: 1.01-1.03; P = 0.003), lower counts of Th2 (HR = 0.95, 95% CI: 0.91-0.99; P = 0.009), and increased percentages of Th17 cells (HR = 1.19, 95% CI: 1.02-1.38; P = 0.024) were associated with 12 month all-cause mortality. Among postprocedural parameters, only increased post-TAVI counts of non-classical monocytes immediately after TAVI were predictive of outcome (HR = 1.03, 95% CI: 1.01-1.05; P = 0.003). The occurrence of SIRS criteria within 48 h post-TAVI showed no significant association with 12 month mortality (HR = 0.57, 95% CI: 0.13-2.43, P = 0.45). In multivariate analysis of discrete or dichotomized clinical and inflammatory variables, the presence of diabetes mellitus (HR = 3.50; 95% CI: 1.42-8.62; P = 0.006), low left ventricular (LV) ejection fraction (HR = 3.16; 95% CI: 1.35-7.39; P = 0.008), increased baseline hsCRP (HR = 5.22; 95% CI: 2.09-13.01; P < 0.0001), and low baseline Th2 cell counts (HR = 8.83; 95% CI: 3.02-25.80) were significant predictors of death. The prognostic value of the linear prediction score calculated of these parameters was superior to the Society of Thoracic Surgeons score (AUC: 0.88; 95% CI: 0.78-0.99 vs. 0.75; 95% CI: 0.64-0.86, respectively; P = 0.036). Finally, when analysing LV remodelling outcomes, ROC curve analysis revealed that low numbers of Tregs (P = 0.017; AUC: 0.69) and increased Th17/Treg ratio (P = 0.012; AUC: 0.70) were predictive of adverse remodelling after TAVI. CONCLUSIONS:Our findings demonstrate an association of specific pre-existing inflammatory phenotypes with increased mortality and adverse LV remodelling after TAVI. Distinct monocyte and T-cell signatures might provide additive biomarkers to improve pre-procedural risk stratification in patients referred to TAVI for severe aortic stenosis.
Project description:STUDY OBJECTIVES:Delirium is a postoperative complication accompanied by disturbances in attention, cognition, arousal, and psychomotor activity. Wrist actigraphy has been advocated to study inactivity and inferred sleep patterns during delirium. We hypothesized that altered patterns of motor activity or immobility, reflective of disordered sleep and wakefulness patterns, would serve as predictive markers of hypoactive postoperative delirium. METHODS:Eighty-four elderly surgical patients were classified into three groups based on the timing of hypoactive delirium following surgery: intact with no delirium throughout postoperative days (POD) 0-5 (n = 51), delirium during POD 0-1 (n = 24), and delirium during POD 2-5 (n = 13). Delirium was detected on daily Confusion Assessment Method evaluations and chart review. Actigraphy measures were calculated from accelerometry signals acquired on the first postoperative day (POD 0, 16:00-23:00) and night (POD 0, 23:00-POD 1, 06:00). RESULTS:Actigraphy metrics showed substantial interpatient variability. Among the three patient groups, only those without delirium showed greater movement during the day compared to night and also fewer minutes of night immobility (P = .03 and P = .02, Wilcoxon rank-sum tests). These patients were poorly discriminated from those with delirium during either POD 0-1 or POD 2-5, using differences in day and night activity (C-statistic, 95% confidence interval [CI]: 0.66 [0.53-0.79] and C-statistic, 95% CI: 0.71 [0.55-0.87], respectively). Inclusion of low-frequency signals improved performance of immobility measures without affecting those based on activity. Cognitively intact patients during POD 0-5 were distinguished from those with delirium during POD 0-1, based on differences in the number of day and night immobile minutes (C-statistic 0.65, 95% CI: [0.53-0.78]). Actigraphy metrics with the strongest association to delirium incidence were not reliably correlated with an increased risk during POD 0-5, when accounting for patient age, sex, intensive care unit admission, and Charlson Comorbidity Index (adjusted odds ratio of 1.7, 95% CI: [1.0-3.0], P = .09, likelihood ratio test). CONCLUSIONS:Early postoperative wrist actigraphy metrics that serve as markers of sleep and wakefulness offer limited capacity as sole predictors or markers of hypoactive delirium. CLINICAL TRIAL REGISTRATION:Registry: ClinicalTrials.gov; Title: Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) Study; Identifier: NCT02241655; URL: https://clinicaltrials.gov/ct2/show/NCT02241655.
Project description:Stroke is one of the most feared complications of aortic valve replacement. Although the outcomes of transcatheter aortic valve implantation (TAVI) improved substantially over time, concerns remained about a potentially higher incidence of stroke with TAVI compared with surgical replacement (SAVR). However, comparative data are sparse. We performed a meta-analysis comparing the incidence of stroke among patients undergoing TAVI versus SAVR. Of the 5067 studies screened, 28 eligible studies (22 propensity-score matched studies and 6 randomized trials) were analyzed. Primary endpoints were 30-day stroke and disabling stroke. Secondary endpoints were 1-year stroke and disabling stroke. A total of 23,587 patients were included, of whom 47.27% underwent TAVI and 52.72% underwent SAVR. For each endpoint, pooled estimates of odds ratio (OR) with 95% confidence interval (CI) were calculated. The pooled estimates for stroke (2.7% vs 3.1%, OR 0.86; 95% CI 0.72 to 1.02; p=0.08) and disabling stroke (2.5% vs 2.9%, OR 0.96; 95% CI 0.57 to 1.62; p=0.89) were comparable following TAVI versus SAVR at 30 days. Similarly, the pooled estimates for stroke (5.0% vs 4.6%, OR 1.01; 95% CI 0.79 to 1.28; p=0.96) and disabling stroke (4.1% vs 4.5%, OR 0.92; 95% CI 0.92 to 1.39; p=0.71) were similar at 1 year. A sensitivity analysis including only RCTs yielded similar results. Our meta-analysis documents comparable rates of strokes and disabling strokes following TAVI or SAVR both at 30 days and 1 year.
Project description:Background: The aim of this systematic review and meta-analysis of clinical trials was to investigate the effects of perioperative sleep disturbances on postoperative delirium (POD). Methods: Authors searched for studies (until May 12, 2020) reporting POD in patients with sleep disturbances following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: We identified 29 relevant trials including 55,907 patients. We divided these trials into three groups according to study design: Seven retrospective observational trials, 12 prospective observational trials, and 10 randomized controlled trials. The results demonstrated that perioperative sleep disturbances were significantly associated with POD occurrence in observational groups [retrospective: OR = 0.56, 95% CI: [0.33, 0.93], I 2 = 91%, p for effect = 0.03; prospective: OR = 0.27, 95% CI: [0.20, 0.36], I 2 = 25%, p for effect < 0.001], but not in the randomized controlled trial group [OR = 0.58, 95% CI: [0.34, 1.01], I 2 = 68%, p for effect = 0.05]. Publication bias was assessed using Egger's test. We used a one-by-one literature exclusion method to address high heterogeneity. Conclusions: Perioperative sleep disturbances were potential risk factors for POD in observational trials, but not in randomized controlled trials.
Project description:OBJECTIVE:Postoperative delirium (POD) was common after spinal surgery, but the main findings in previous studies remained conflicting. This current meta-analysis was aimed at exploring the prevalence and risk factors of POD after spinal surgery. METHODS:PubMed and Embase were searched from inception to June 2019. Studies which reported the prevalence and risk factors of POD after spinal surgery were included. STATA version 12.0 was employed to analyze the pooled data. Statistical heterogeneity across included studies was identified using the I2 statistics. RESULTS:A total of 28 studies with 588,732 patients were included in the meta-analysis. The pooled prevalence of POD after spinal surgery was 0.85% (95%CI, 0.83-0.88%) with substantial heterogeneity (I2 = 97.3%). The central nervous system disorder (OR 4.73; 95%CI, 4.30-5.19) was a strong predictor for POD, whereas age (OR 1.16; 95%CI, 1.05-2.47; I2 = 99.2%) and blood loss (OR 1.10; 95%CI, 1.01-1.20; I2 = 93.3%) were weaker predictors. The funnel plot and statistical tests suggested that there existed potential publication bias, but the trim and fill method indicated that the pooled prevalence basically kept stable after adding two "missing" studies. CONCLUSIONS:The pooled POD after spinal surgery ranges from 0.83 to 0.88%. The central nervous system disorder, age, and blood loss were potential risk factors for POD.
Project description:<b><i>Background:</i></b> Transcatheter aortic valve implantation (TAVI) has been widely used as a valued alternative to surgical aortic valve replacement. In cardiovascular surgeries, discharge disposition has been widely investigated. We examined the prevalence and predictors of non-home discharge after TAVI, and the prognosis based on discharge destination. <b><i>Methods?and?Results:</i></b> We retrospectively analyzed 732 consecutive patients undergoing TAVI, and divided them into 2 groups: the home group (discharged directly home; n=678 [92.6%]) and the non-home group (n=54 [7.4%]). From baseline and procedural characteristics, peripheral artery disease (PAD; odds ratio [OR] 2.73; 95% confidence interval [CI] 1.25-5.97; P=0.012), previous stroke (OR 2.57; 95% CI 1.03-6.45; P=0.045), albumin level (OR 0.16 per 1-g/dL increase; 95% CI 0.07-0.39; P<0.001), and procedural stroke (OR 31.6; 95% CI 10.9-91.7; P<0.001) were independently associated with non-home discharge. In Kaplan-Meier analysis, the non-home group had worse survival than the home group (log-rank, P=0.001). In multivariate analysis, male sex, atrial fibrillation or atrial flutter, and low albumin concentrations were associated with all-cause mortality, but non-home discharge was not (P=0.18). <b><i>Conclusions:</i></b> Non-home discharge was recorded for 7.4% of patients undergoing TAVI, and was associated with PAD, nutritional status, and previous and procedural stroke. Non-home discharge reflects worse baseline characteristics, and may be a marker of mid-term outcome after TAVI.
Project description:OBJECTIVES:Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium. DESIGN:Prospective observational study. SETTING:Single-centre at a European academic hospital. PRIMARY AND SECONDARY OUTCOME MEASURES:In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD. RESULTS:A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95%?CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95%?CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95%?CI 1.04 to 12.99) and age (OR 3.02; 95%?CI 1.06 to 8.62) to be independently associated with the development of POD. CONCLUSIONS:We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.
Project description:Temporal and surgical risk dependent associations with clinical outcomes in patients receiving transcatheter versus surgical aortic valve implantation (TAVI vs SAVI) are uncertain. In this meta-analysis, 7 randomized controlled trials (7,771 patients) were included to investigate trends in outcomes in TAVI versus SAVI up to 5 years, and variation in outcomes with respect to low-, intermediate-, and high-surgical risk of the patients up to 1 year. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI). All-cause mortality was similar in TAVI and SAVI at 30 days (HR 0.81, 95% CI 0.55 to 1.21, p?=?0.31), 1 year (HR 0.97, 95% CI 0.89 to 1.06, p?=?0.49), 2 years (HR 0.96, 95 CI 0.85 to 1.09, p?=?0.54), and 5 years (HR 1.04, 95% CI 0.89 to 1.21, p?=?0.62). Cardiac mortality, myocardial infarction and stroke were similar in both interventions up to 5 years. TAVI was associated with lower risk of atrial fibrillation, but higher risk of vascular complications, pacemaker implantation, and paravalvular leak up to 5 years. The lower risks of major bleeding and acute kidney injury with TAVI versus SAVI were limited to 1 and 2 years, respectively. Compared with SAVI, TAVI was superior in reducing all-cause mortality in low surgical risk patients at 30 days only, whereas TAVI was noninferior to SAVI in intermediate- and high-risk patients at 30 days and across all risks at 1 year. In conclusion, TAVI was noninferior to SAVI in terms of mortality, myocardial infarction, and stroke up to 5 years. TAVI improved survival versus SAVI in low-risk patients at 30 days.