title: Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality.
abstract: OBJECTIVE
  The purpose of this study was to determine the incidence and clinical significance of postoperative delirium (PD) in patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR).
  
  
  METHODS
  Between 2010 and 2013, 427 patients underwent TAVR (n = 168) or SAVR (n = 259) and were screened for PD using the Confusion Assessment Method for the Intensive Care Unit. The incidence of PD in both treatment groups was determined and its association with morbidity and mortality was retrospectively compared.
  
  
  RESULTS
  PD occurred in 135 patients (32%) with a similar incidence between SAVR (33% [86 out of 259]) and TAVR (29% [49 out of 168]) (P = .40). TAVR by transfemoral approach had the lowest incidence of PD compared with SAVR (18% vs 33%; P = .025) or TAVR when performed by alternative access techniques (18% vs 35%; P = .02). Delirium was associated with longer initial intensive care unit stay (70 vs 27 hours), intensive care unit readmission (10% [14 out of 135] vs 2% [6 out of 292]), and longer hospital stay (8 vs 6 days) (P < .001 for all). PD was associated with increased mortality at 30 days (7% vs 1%; P < .001) and 1 year (21% vs 8%; P < .001). After multivariable adjustment, PD remained associated with increased 1-year mortality (hazard ratio, 3.02; 95% confidence interval, 1.75-5.23; P < .001). There was no interaction between PD and aortic valve replacement approach with respect to 1-year mortality (P = .12). Among propensity-matched patients (n = 170), SAVR-treated patients had a higher incidence of PD than TAVR-treated patients (51% vs 29%; P = .004).
  
  
  CONCLUSIONS
  PD occurs commonly after SAVR and TAVR and is associated with increased morbidity and mortality. Given the high incidence of PD and its associated adverse outcomes, further studies are needed to minimize PD and potentially improve patient outcomes.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo. Electronic address: maniarh@wudosis.wustl.edu.
authors.forename: Hersh S
authors.initials: HS
authors.lastname: Maniar
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Lindman
authors.affiliation: Department of Anesthesia, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Krisztina
authors.initials: K
authors.lastname: Escallier
authors.affiliation: Department of Anesthesia, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Michael
authors.initials: M
authors.lastname: Avidan
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Eric
authors.initials: E
authors.lastname: Novak
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Spencer J
authors.initials: SJ
authors.lastname: Melby
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Marci S
authors.initials: MS
authors.lastname: Damiano
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: John
authors.initials: J
authors.lastname: Lasala
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Nishath
authors.initials: N
authors.lastname: Quader
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Ravinder Singh
authors.initials: RS
authors.lastname: Rao
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lawton
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Marc R
authors.initials: MR
authors.lastname: Moon
authors.affiliation: Department of Anesthesia, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Daniel
authors.initials: D
authors.lastname: Helsten
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Pasque
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: Damiano
authors.affiliation: Division of Cardiology, Department of Medicine, Barnes Jewish Hospital/Washington University School of Medicine, St Louis, Mo.
authors.forename: Alan
authors.initials: A
authors.lastname: Zajarias
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D003693:Delirium / Q000175:diagnosis / Q000209:etiology / Q000401:mortality* / Q000628:therapy; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D015999:Multivariate Analysis; D010359:Patient Readmission; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: TAVR; aortic stenosis; aortic valve replacement; cardiac surgery; delirium