Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis

doi:10.1053/j.jvca.2017.03.016

Journal of Cardiothoracic and Vascular Anesthesia

Volume 31, Issue 6, December 2017, Pages 1977-1984

https://doi.org/10.1053/j.jvca.2017.03.016 Get rights and content

Objective

To investigate the risk factors for postoperative delirium and the impact of delirium on mortality and morbidity following transcatheter aortic valve implantation (TAVI).

Design

Patients who underwent TAVI were identified using the International Classification of Diseases, 9th revision clinical modification codes from the National Inpatient Sample database. Statistical analysis of preoperative and perioperative risk factors was done to identify the independent risk factors for delirium after TAVI.

Setting

Multi-institutional.

Participants

Patients who underwent TAVI from 2012 to 2013.

Interventions

TAVI.

Measurements and Main Results

Over the period of 2 years (2012-2013), 7,566 patients underwent TAVI. The incidence of delirium post-TAVI was 4.57% (345). Age >85 (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.05; p = 0.003), electrolyte abnormalities (OR 1.83; 95% CI 1.17-2.87; p = 0.008), prior neurologic illness (OR 1.67; 95% CI 1.10-3.15; p = 0.01), and weight loss in the hospital (OR 1.77; 95% CI 1.05-2.99; p = 0.03) were independent risk factors for postoperative delirium (POD). Unilateral or bilateral carotid stenosis did not predispose to the development of delirium. POD was an independent risk factor for procedural morbidity (OR 3.29; 95% CI 2.05-5.28; p < 0.001). POD did not increase the risk of in-house mortality after TAVI.

Conclusion

Age of >85, electrolyte disturbance, pre-existing neurologic disease and weight loss were found to be independent risk factors for delirium. POD was associated significantly with morbidity. Owing to a significant increase in the morbidity, a thorough screening protocol and effective strategies to predict, prevent, and treat postoperative delirium would reduce the cost associated with TAVI.

Section snippets

Data Source

The National Inpatient Sample (NIS), which is the largest publicly accessible inpatient administrative database in the United States, was used for this study. It includes patient demographic data, hospital characteristics, diagnosis, severity status, procedures and interventions performed and discharge information. Data extraction was performed using the International Classification of Diseases, 9th revision clinical modification (ICD-9-CM) diagnosis codes in addition to Projection Clinical

Patient Characteristics

Over the period of 2 years (2012-2013), 7,566 patients underwent TAVI. All relevant data pertaining to these patients were extracted. The mean age of the population was 81 years with near-equal sex distribution (female 49.28%; male 50.72%). Whites, nearly 87.5%, formed the majority of the study population. While the average VWR score was 5.62 ± 0.25, subjects were almost equally distributed between low risk (<5) and moderate risk (5-14) categories (45.80% and 46.81%, respectively) (Table 2).

Comorbidities in Patients With POD

The

Discussion

POD is estimated to occur in about 5% to 50% of patients following a surgery.26, 27 This finding is clinically alarming as it can trigger a chain of clinically deleterious events like prolonged hospitalizations, loss of functional independence,14, 28, 29 and declining cognitive function.27, 30 In the present study, the incidence of POD was found to be about 4.57%. This was in contrast to the current published literature in which the incidence rates ranged anywhere from 8% to 37%2, 9, 31 (Table 8

Study Limitations

This study was conducted using the NIS, a database that allows for analysis of large numbers of patients treated in the real-world general hospital setting. Being an administrative discharge level database, the NIS relies on adequate coding of diagnosis and procedures by the reporting institutions. Incorrect coding or inadequate coding of all preoperative diagnoses could have impacted the data analyzed. Another major limitation of this study was the fact that delirium is not routinely looked

Conclusion

Advanced age (>85 years), electrolyte disturbance, pre-existing neurologic disease, and weight loss were found to be independent risk factors for POD. Carotid artery disease did not appear to significantly increase the risk of delirium after TAVI. Patients with postprocedural delirium have prolonged in-patient stays and require more frequent discharge to locations other than home. Owing to a significant increase in the morbidity, a thorough screening protocol and effective strategies to

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Cited by (21)

The Impact of Cognitive Impairment on Clinical Outcomes After Transcatheter Aortic Valve Implantation (from a Systematic Review and Meta-Analysis)
2022, American Journal of Cardiology
Citation Excerpt :
Of 1,133 studies, we reviewed 159 full-text publications. A total of 14 studies with 32,746 patients (5,098 patients with cognitive impairment at baseline and 27,648 without) were included in our manuscript (Figure 1).28–41 A total of 11 studies (24,562 patients) reported on mortality, whereas 6 studies (25,954 patients) reported on POD.
This study sought to investigate the impact of pre-existing cognitive impairment on outcomes after transcatheter aortic valve implantation (TAVI). TAVI has been increasingly used in seniors, and evidence suggests better outcomes than surgical aortic valve replacement. Although frailty has been shown to be associated with poorer outcomes after TAVI, the effect of pre-existing cognitive impairment on patient outcomes after TAVI remains unclear. We searched the Medline, Embase, Scopus and Cochrane databases until May 14, 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was short-term (6 months to 1 year) mortality, and secondary outcomes included long-term (1 year to 3 years) mortality, in-hospital mortality, and postoperative delirium. A total of 14 studies with 32,746 patients (5,098 patients with cognitive impairment at baseline, 27,648 without) were included in our meta-analysis. Among studies that reported the raw proportion of patients with mortality of postoperative delirium, cognitive impairment significantly increased mortality (risk ratio 2.10, 95% confidence intervals [CIs] 1.43 to 3.08, p = 0.0002) and postoperative delirium (risk ratio 2.27, 95% CI 1.76 to 2.93, p <0.0001). Studies which reported the hazards for mortality (pooled hazards ratio 1.97, 95% CI 1.50 to 2.60, p <0.0001) and odds of postoperative delirium (pooled odds ratio 2.40, 95% CI: 1.51 to 3.80, p = 0.0002) yielded results consistent with the primary meta-analysis. In conclusion, pre-existing cognitive impairment is a significant risk factor for poorer outcomes after TAVI and should be carefully considered in this group of patients. Guidelines and future studies should take cognitive impairment into consideration for preoperative risk stratification.
Incidence and risk factors of postoperative delirium following total knee arthroplasty: A retrospective Nationwide Inpatient Sample database study
2022, Knee
Citation Excerpt :
Nonetheless, the exact relationship between racial difference and postoperative delirium remains unclear and hence requires further study. Not surprisingly, when using the same NIS or similar database, the incidence of postoperative delirium after TKA is close to that of other elective orthopaedic operations, including total hip arthroplasty (0.90%), total shoulder arthroplasty (0.56%), and lumbar spine surgery (0.80%) and other non-orthopaedic procedures including major surgical oncology surgery (1% to 1.57%), surgery for primary lung cancer (2%), transcatheter aortic valve implantation (4.57%), which further confirming the aforementioned lower incidence of delirium based on administrative database [29,35–39]. Regarding to another demographic characteristic, patients with postoperative delirium were significantly older than those without.
Postoperative delirium is a common complication following major surgeries, causing a variety of adverse effects. However, the incidence and risk factors of delirium after primary total knee arthroplasty (TKA) has not been well studied using a large-scale national database.
A retrospective database analysis was performed based on Nationwide Inpatient Sample (NIS) from 2005-2014. Patients who underwent primary TKA were included. Patient demographics, comorbidities, length of stay (LOS), total charges, type of payer, in-hospital mortality, and perioperative complications were evaluated.
A total of 1,228,879 TKAs were obtained from the NIS database. The general incidence of delirium after TKA was 1.00%, which peaked in the year 2008. Patients with delirium after TKA presented increased comorbidities, LOS, hospital charges, usage of medicare, and in-hospital mortality (P < 0.0001). Delirium following TKA was associated with medical complications during hospitalization including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, and urinary tract infection. Risk factors of postoperative delirium included advanced age, neurological disorders, alcohol and drug abuse, depression, psychoses, fluid and electrolyte disorders, diabetes, weight loss, deficiency and chronic blood loss anemia, coagulopathy, congestive heart failure, chronic pulmonary disease, pulmonary circulation disorders, peripheral vascular disorders, chronic renal failure, and teaching hospital. Notably, neurological disorders were found to have the strongest association with the occurrence of postoperative delirium.
A relatively low incidence of delirium after TKA was identified. It is of benefit to study risk factors of postoperative delirium to ensure the appropriate management and moderate its consequences.
Delirium Predicts Worse Outcomes in Both Transcatheter and Surgical Aortic Valve Replacement
2021, JACC: Cardiovascular Interventions
Impact of delirium in acute cardiac care unit after transcatheter aortic valve replacement
2021, International Journal of Cardiology
Citation Excerpt :
Our study is one of the first to describe both the incidence and risk factors associated with delirium specifically in patients admitted to an ACCU after TAVR. The incidence observed in this study is consistent with other similar studies, which report rates of up to 29% [1,3,11–14]. As expected, this rate is lower than that reported after surgical aortic valve replacement [3], despite the TAVR population being older and more comorbid.
Delirium is a cognitive disorder that commonly occurs during hospitalization in acute cardiac care units (ACCU), but its effect after transcatheter aortic valve replacement (TAVR) has not been well evaluated. The objective of this study is to determine the incidence, predictive factors and prognostic impact of delirium following TAVR.
A total of 501 consecutive patients admitted to an ACCU after TAVR were included. The Confusion Assessment Method was used to evaluate delirium during ACCU stay. Risk factors, preventive pharmacological treatment, peri-procedural characteristics and complications were assessed. Clinical events were recorded with a median follow-up of 24 months.
The incidence of delirium after TAVR was 22.0% (n = 110). Previous cognitive impairment (OR 4.17; 95% CI 1.11–15.71; p = 0.035), peripheral arterial disease (OR 4.54; 95% CI 1.79–11.54; p = 0.001), the use of general anaesthesia (OR 2.55; 95% CI 1.32–4.90; p = 0.005), and prolonged mechanical ventilation (OR 18.86; 95% CI 1.85–192.58; p = 0.013) were significantly associated with the development of delirium. Patients with delirium had a greater hospital length of stay (7.5 [5.5–13.5] vs 5.6 [4.6–8.2] days, mean difference − 3.49; 95% CI -5.45 to −1.52; p < 0.001), and higher in-hospital (OR 2.68; 95% CI 1.02–6.99; p = 0.045), 1-year (HR 2.09; 95% CI 1.13–3.87; p = 0.018) and 2-year mortality (HR 1.94; 95% CI 1.12–3.34; p = 0.017).
Delirium is a frequent complication in patients admitted to ACCU after TAVR, and is associated with prolonged hospital stay and higher in-hospital and mid-term mortality.
Delirium After TAVR: Crosspassing the Limit of Resilience
2020, JACC: Cardiovascular Interventions
Citation Excerpt :
Of these studies, the majority (11 of 19) had retrospective designs. The largest patient populations were studied in International Classification of Diseases datasets that keep track of raw data for nationwide registries and/or insurance companies (9,21,35,38). The relatively low incidences demonstrated by these studies (2% to 8%) suggest misclassification and underreporting of the true incidence of POD after TAVR.
Patients who undergo transcatheter aortic valve replacement often are frail and elderly. Delirium is a frequently observed complication, associated with impaired recovery, prolonged hospital stay, and mortality. In different hospital settings, interventions that reduced the incidence of delirium resulted in improved clinical outcome and reduced costs. In that context, prevention, early recognition, and timely interventions could be the next step toward better outcomes of transcatheter aortic valve replacement. This review is focused on awareness and recognition of delirium, including predisposing “vulnerability” factors (such as cognitive impairment and carotid artery disease) and “trigger” factors (such as anesthesia, hemodynamic imbalance, and complications). For prevention and treatment, clinicians should focus on sleep hygiene, orientation, pain management, and early mobilization. In case of delirium, a thorough search and treatment of trigger factors is warranted. Future studies should focus on risk assessment, preventive and therapeutic interventions, and their potential benefit in terms of costs and clinical outcomes.
Initiative for Prevention and Early Identification of Delirium in Medical-Surgical Units: Lessons Learned in the Past Five Years
2019, American Journal of Medicine
Citation Excerpt :
We report the rate of delirium among patients who were screened to be at high risk of delirium, as this was our target population for preventing delirium (n = 21,465). We defined a patient to have “delirium” if they either had an ICD code for delirium (not present on admission; Supplementary Table 2, available online),40–48 or required a sitter (ie, trained personnel at bedside to keep the patient oriented and safe) or physical restraints during that encounter (Supplementary Table 3, available online). These included LOS, inpatient mortality, and discharge to a nursing home.
Delirium is an acute change in mental status affecting 10%-64% of hospitalized patients, and may be preventable in 30%-40% of cases. In October 2013, a task force for delirium prevention and early identification in medical-surgical units was formed at our hospital. We studied whether our standardized protocol prevented delirium among high-risk patients.
We studied 105,455 patient encounters between November 2013 and January 2018. Since November 2013, there has been ongoing education to decrease deliriogenic medications use. Since 2014, nurses screen all patients for presence or absence of delirium using the Confusion Assessment Method (CAM). Since 2015, nurses additionally screen all patients for risk of delirium. In 2015, a physician order set for delirium was created. Nonpharmacological measures are implemented for high-risk or CAM positive patients.
98.8% of patient encounters had CAM screening, and 99.6% had delirium risk screening. Since 2013, odds of opiate use decreased by 5.0% per year (P < .001), and odds of benzodiazepine use decreased by 8.0% per year (P < .001). There was no change in anticholinergic use. In the adjusted analysis, since 2015, odds of delirium decreased by 25.3% per year among high-risk patients (n = 21,465; P < .001). Among high-risk patients or those diagnosed with delirium (n = 22,121), estimated length of stay decreased by 0.13 days per year (P < .001), odds of inpatient mortality decreased by 16.0% per year (P = .011), and odds of discharge to a nursing home decreased by 17.1% per year (P < .001).
With high clinician engagement and simplified workflows, our delirium initiative has shown sustained results.

View all citing articles on Scopus

: The authors declare no sources of funding and no conflict of interest.

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Original ArticleDelirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis

Objective

Design

Setting

Participants

Interventions

Measurements and Main Results

Conclusion

Section snippets

Data Source

Patient Characteristics

Comorbidities in Patients With POD

Discussion

Study Limitations

Conclusion

Lancet (London, England)

Ann Thorac Surg

JACC Cardiovasc Interv

J Thorac Cardiovasc Surg

Lancet

J Psychosom Res

J Am Coll Cardiol

Neurobiol Aging

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Br J Anaesth

Psychiatry Res

Postoperative delirium following transcatheter aortic valve implantation: A historical cohort study

Can J Anaesth

Postoperative delirium and health related quality of life after coronary artery bypass grafting

Scand Cardiovasc J

Outcomes associated with postoperative delirium after cardiac surgery

Am J Crit Care

Measures of executive function and depression identify patients at risk for postoperative delirium

Anesthesiology

Incidence and precipitating factors of delirium after coronary artery bypass grafting

Scand Cardiovasc J

Encephalopathy and stroke after coronary artery bypass grafting: Incidence, consequences, and prediction

Arch Neurol

Effect of asymptomatic carotid artery disease on cognitive outcome after cardiopulmonary bypass

J Int Neuropsychol Soc

Atherosclerosis is associated with delirium after coronary artery bypass graft surgery

J Am Geriatr Soc

Intracranial cerebral artery disease as a risk factor for central nervous system complications of coronary artery bypass graft surgery

Stroke

Delirium: An independent predictor of functional decline after cardiac surgery

J Am Geriatr Soc

Postoperative delirium. Part 1: Pathophysiology and risk factors

Eur J Anaesthesiol

Transcatheter or surgical aortic-valve replacement in intermediate-risk patients

N Engl J Med

Original Article
Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis