TAVR Post-Operative Delirium Incidence: Transfemoral vs Nontransfemoral Access

Post-operative delirium (POD) after transcatheter aortic valve replacement (TAVR) occurred at an incidence of approximately 13% in a retrospective observational cohort study conducted at the University Medical Center Utrecht in the Netherlands. Results were recently published in JACC: Cardiovascular Interventions.

Researchers evaluated 260 patients who underwent TAVR and found POD was most frequently diagnosed the second day after the procedure. Developing POD was associated with a prolonged hospital stay, impaired long-term survival, and various post-procedural complications, including major vascular complications and bleeding, stroke, acute kidney injury, atrial fibrillation, and infectious disease.

POD was diagnosed according to Diagnostic and Statistical Manual-IV (DSM-IV) criteria and there were no cases of delirium prior to the TAVR procedures. Independent predictors of POD included nontransfemoral access (odds ratio [OR]: 7.74; 95% confidence interval [CI]: 3.26-18.10), smoking status (OR: 3.99; 95% CI: 1.25-12.80), carotid artery disease (OR: 3.88; 95% CI: 1.50-10.10), atrial fibrillation (OR: 2.74; 95% CI: 1.17-6.37), and age (OR: 1.08; 95% CI: 1.00-1.17).

Overall mortality was 18% after a median follow-up period of 16 months. Mortality rates were higher in patients who developed POD in transfemoral TAVR (39% vs 13%; P=.003), but not in nontransfemoral TAVR (33% vs 36%; P=.841). POD remained a predictor of mortality in transfemoral TAVR but not in nontransfemoral TAVR (HR: 2.81; 95% CI: 1.16-6.83 and HR: 0.43; 95% CI: 0.10-1.76, respectively).

These results suggest that incidence of POD is significantly tied to procedural access, with a 5-fold higher rate in nontransfemoral TAVR compared with transfemoral TAVR.

Researchers noted that while many “predisposing and precipitating factors of delirium are nonmodifable,” nonpharmacological measures can be taken, especially for vulnerable patients. “Specifically, in the TAVR setting, it seems advisable to avoid nontransfemoral access whenever justified,” they stated. “To date, there is no consensus on the efficacy of pharmacological therapy in the prevention and treatment of delirium.”

“Early recognition and prevention strategies may decrease the incidence of POD and improve outcomes in TAVR patients,” researchers concluded. “Future large prospective studies are needed to confirm these first findings on POD after TAVR.”

Reference

Abawai M, Nijhoff F, Agostoni P, et al. Incidence, predictive factors, and effect of delirium after transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2016;9(2):160-168. doi: 10.1016/j.jcin.2015.09.037.