Delirium after Aortic Valve Therapy. A Prospective Cohort Study of Octogenarian Patients following Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Implantation.

Introduction: Untreated and symptomatic aortic stenosis (AS) is associated with high mortality. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are two treatment options for patients with severe AS. Patients receiving SAVR and TAVI are often 80 years and older. Delirium, an acute state of confusion characterized by temporary and fluctuating decline in attention and cognition, is common in older patients after cardiac surgery. Yet, knowledge about octogenarians undergoing invasive cardiovascular therapy is scarce, and delirium after TAVI remains to be systematically explored. Aims: The overall aim of this study was to investigate delirium in octogenarian patients undergoing SAVR or TAVI by determining its incidence, identifying risk factors, describing its onset and time course, and by determining if delirium can be used to predict physical and cognitive function, self-reported health status, first-time hospital readmissions and mortality 1 and 6 months after aortic valve treatment. Materials and Methods: This is a prospective cohort study of octogenarian patients with AS, scheduled for elective treatment with SAVR or TAVI at a tertiary university hospital in western Norway. Delirium was the main outcome of the study. Inclusion criteria were: age 80 years-old and older and previous acceptance for treatment with SAVR or TAVI. Exclusion criteria were: denied consent to participate in the study and inability to speak Norwegian. Between 2011 and 2013, 143 patients were included in the study. Demographic and clinical information was collected from hospital information system registers, patients’ medical records or by interviewing included patients, as appropriate. Delirium was assessed for 5 postoperative days with the Confusion Assessment Method. Activities of daily living, instrumental activities of daily living and self-reported health status were measured with the Barthel Index, the Nottingham Extended Activities of Daily Living Scale (IADL) and The 12-Item Short Form Health Survey (SF-12), at baseline and at 1 and 6-month follow-up. Cognitive status was assessed at baseline and at 6-month follow-up with the Mini-Mental State Examination (MMSE). Results: The mean age of included patients was 83.5 years (SD 2.7) and TAVI was performed in 46% of them. Patients undergoing SAVR had a higher incidence of delirium than patients treated with TAVI (66% vs 44%, p = 0.01). Multivariate logistic regression analysis revealed that reduced cognitive function at baseline (p = 0.03) and treatment with SAVR (p = 0.02) are risk factors for delirium in octogenarian patients after aorta valve treatment. No differences in the number of days with delirium were found between patient groups (p = 0.20) but the onset and course of delirium in patients treated with SAVR was more unpredictable (p = 0.003) than it was in patients treated with TAVI (Paper I). Patients with and without delirium after SAVR had lower IADL function at 1-month follow-up (scores from 58 to 42 and from 58 to 50 respectively p ≤ 0.02). However, this function returned to baseline levels after 6 months. Improvements in the Physical Component Summary score of SF-12 were found in patients not having delirium and treated with SAVR (from 39 to 48, p < 0.001). No differences between patient groups in other outcomes were identified. Regression models suggest that delirium after SAVR might predict IADL scores1-month after treatment (not significant, p-values ≤ 0.07) but does not predict large differences in ADL, cognitive function or SF-12 scores in octogenarian AS patients. Patients experiencing delirium after TAVI had a lower ADL (from 19 to 16, p < 0.001) and IADL function (from 49 to 40, p = 0.003) 1 month after the procedure. In TAVI patients without delirium, the physical component score of SF-12 increased after 1 and 6 months (30 to 35, p = 0.04 and 30 to 35, p = 0.02 respectively). Regression analyses established that delirium following TAVI predicted lower ADL and IADL function at 1 but not at 6-month follow-up (Paper II). First-time readmissions and death 1 and 6 months after SAVR or TAVI were more common in octogenarian patients who experienced delirium. The effect of delirium was greatest during the first two months after discharge (adjusted hazard ratio 2.9 (95% CI: 1.5 to 5.7).The most common discharge diagnosis at readmission was related to the circulatory system (Paper III). Conclusions: Delirium is often present after aortic valve treatment, especially in patients receiving SAVR. In addition to be a risk factor for delirium in octogenarian patients, SAVR was associated with a more unpredictable onset and course of delirium. Patients who experienced delirium, regardless treatment type, appear to have lower short-term IADL function. Yet, delirium does not seem to confer long-term reductions in physical, mental or self-reported health status in this patient group. Compared to patients without delirium, first-time readmissions and mortality were more common 6 months after hospital discharge in patients who had experienced delirium. Our study provides additional evidence showing that delirium is a serious hospital complication that could be associated with negative outcomes such as lower physical function, morbidity and mortality 1 and 6 months after aortic valve treatment, also when more gentle techniques like TAVI are used. These findings are also relevant when designing future studies and implementing strategies that could lead to the prevention of delirium in other older patient populations

Baseline frailty status and outcomes important for shared decision-making in older adults receiving transcatheter aortic valve implantation, a prospective observational study.

AIMS The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis. CONCLUSIONS TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids

Delirium after Aortic Valve Therapy. A Prospective Cohort Study of Octogenarian Patients following Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Implantation.

Introduction: Untreated and symptomatic aortic stenosis (AS) is associated with high mortality. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are two treatment options for patients with severe AS. Patients receiving SAVR and TAVI are often 80 years and older. Delirium, an acute state of confusion characterized by temporary and fluctuating decline in attention and cognition, is common in older patients after cardiac surgery. Yet, knowledge about octogenarians undergoing invasive cardiovascular therapy is scarce, and delirium after TAVI remains to be systematically explored. Aims: The overall aim of this study was to investigate delirium in octogenarian patients undergoing SAVR or TAVI by determining its incidence, identifying risk factors, describing its onset and time course, and by determining if delirium can be used to predict physical and cognitive function, self-reported health status, first-time hospital readmissions and mortality 1 and 6 months after aortic valve treatment. Materials and Methods: This is a prospective cohort study of octogenarian patients with AS, scheduled for elective treatment with SAVR or TAVI at a tertiary university hospital in western Norway. Delirium was the main outcome of the study. Inclusion criteria were: age 80 years-old and older and previous acceptance for treatment with SAVR or TAVI. Exclusion criteria were: denied consent to participate in the study and inability to speak Norwegian. Between 2011 and 2013, 143 patients were included in the study. Demographic and clinical information was collected from hospital information system registers, patients’ medical records or by interviewing included patients, as appropriate. Delirium was assessed for 5 postoperative days with the Confusion Assessment Method. Activities of daily living, instrumental activities of daily living and self-reported health status were measured with the Barthel Index, the Nottingham Extended Activities of Daily Living Scale (IADL) and The 12-Item Short Form Health Survey (SF-12), at baseline and at 1 and 6-month follow-up. Cognitive status was assessed at baseline and at 6-month follow-up with the Mini-Mental State Examination (MMSE). Results: The mean age of included patients was 83.5 years (SD 2.7) and TAVI was performed in 46% of them. Patients undergoing SAVR had a higher incidence of delirium than patients treated with TAVI (66% vs 44%, p = 0.01). Multivariate logistic regression analysis revealed that reduced cognitive function at baseline (p = 0.03) and treatment with SAVR (p = 0.02) are risk factors for delirium in octogenarian patients after aorta valve treatment. No differences in the number of days with delirium were found between patient groups (p = 0.20) but the onset and course of delirium in patients treated with SAVR was more unpredictable (p = 0.003) than it was in patients treated with TAVI (Paper I). Patients with and without delirium after SAVR had lower IADL function at 1-month follow-up (scores from 58 to 42 and from 58 to 50 respectively p ≤ 0.02). However, this function returned to baseline levels after 6 months. Improvements in the Physical Component Summary score of SF-12 were found in patients not having delirium and treated with SAVR (from 39 to 48, p < 0.001). No differences between patient groups in other outcomes were identified. Regression models suggest that delirium after SAVR might predict IADL scores1-month after treatment (not significant, p-values ≤ 0.07) but does not predict large differences in ADL, cognitive function or SF-12 scores in octogenarian AS patients. Patients experiencing delirium after TAVI had a lower ADL (from 19 to 16, p < 0.001) and IADL function (from 49 to 40, p = 0.003) 1 month after the procedure. In TAVI patients without delirium, the physical component score of SF-12 increased after 1 and 6 months (30 to 35, p = 0.04 and 30 to 35, p = 0.02 respectively). Regression analyses established that delirium following TAVI predicted lower ADL and IADL function at 1 but not at 6-month follow-up (Paper II). First-time readmissions and death 1 and 6 months after SAVR or TAVI were more common in octogenarian patients who experienced delirium. The effect of delirium was greatest during the first two months after discharge (adjusted hazard ratio 2.9 (95% CI: 1.5 to 5.7).The most common discharge diagnosis at readmission was related to the circulatory system (Paper III). Conclusions: Delirium is often present after aortic valve treatment, especially in patients receiving SAVR. In addition to be a risk factor for delirium in octogenarian patients, SAVR was associated with a more unpredictable onset and course of delirium. Patients who experienced delirium, regardless treatment type, appear to have lower short-term IADL function. Yet, delirium does not seem to confer long-term reductions in physical, mental or self-reported health status in this patient group. Compared to patients without delirium, first-time readmissions and mortality were more common 6 months after hospital discharge in patients who had experienced delirium. Our study provides additional evidence showing that delirium is a serious hospital complication that could be associated with negative outcomes such as lower physical function, morbidity and mortality 1 and 6 months after aortic valve treatment, also when more gentle techniques like TAVI are used. These findings are also relevant when designing future studies and implementing strategies that could lead to the prevention of delirium in other older patient populations

Comparison of frequency, risk factors, and time course of postoperative delirium in octogenarians after transcatheter aortic valve implantation versus surgical aortic valve replacement

Postoperative delirium (PD) after transcatheter aortic valve implantation (TAVI) remains to be explored. We sought to (1) determine the incidence of PD in octogenarians who underwent TAVI or surgical aortic valve replacement (SAVR), (2) identify its risk factors, and (3) describe possible differences in the onset and course of PD between treatment groups. A prospective cohort study of consecutive patients aged ≥80 years with severe aortic stenosis who underwent elective TAVI or SAVR (N = 143) was conducted. The incidence of PD was assessed for 5 days using the Confusion Assessment Method (CAM). Risk factors for PD were studied with logistic regression. Patients treated with TAVI were older (p ≤0.001), had lower cognitive scores (p = 0.007), and more co-morbidities (p = 0.003). Despite this, significantly fewer (p = 0.013) patients treated with TAVI (44%) experienced PD compared to patients treated with SAVR (66%). Undergoing SAVR (p = 0.02) and having lower cognitive function (p = 0.03) emerged as risk factors for PD, whereas gender, activities of daily living, frailty, atrial fibrillation, and postoperative use of opioids and anxiolytics did not. Patients treated with TAVI and without PD during the first 2 postoperative days were unlikely to experience PD on subsequent days. The onset of PD after SAVR could occur at any time during the postoperative evaluation. In conclusion, SAVR in octogenarian patients with aortic stenosis might be considered as a predisposing factor for PD. Our data also suggest that the onset of PD was more unpredictable after SAVR

Indwelling urinary catheters, aortic valve treatment and delirium: a prospective cohort study

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

Indwelling urinary catheters, aortic valve treatment and delirium: a prospective cohort study

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.publishedVersio

A novel Geriatric Assessment frailty score predicts two-year mortality after Transcatheter Aortic Valve implantation

Aims Established surgical scores have limitations in delineating risk among candidates for transcatheter aortic valve implantation (TAVI). Assessment of frailty might help to estimate the mortality risk and identify patients likely to benefit from treatment. The aim of the study was to develop a frailty score to guide the decision for TAVI. Methods and results We conducted a prospective observational study in patients ≥70 years referred for TAVI during 2011–15. A Heart Team had declined the patients for open heart surgery due to high risk but accepted them for TAVI. Prior to the procedure, a geriatric assessment (GA) was performed. Based on this, an 8-element frailty score with a 0–9 (least frail–most frail) scale was developed. A total of 142 patients, 54% women, mean age 83 (standard deviation 4) years, with severe and symptomatic aortic stenosis were assessed. All-cause 2 year mortality was 11%. The novel GA frailty score predicted 2-year mortality in Cox analyses, also when adjusted for age, gender, and logistic EuroSCORE [hazard ratio (HR) 1.75, 95% confidence interval (CI): 1.28–2.42, P < 0.001]. A receiver operating characteristic (ROC) curve analysis indicated that a GA frailty score cut-off at ≥4 predicted 2-year mortality with a specificity of 80% (95% CI: 73–86%) and a sensitivity of 60% (95% CI: 36–80%). The area under the curve was 0.81 (95% CI 0.71–0.90). Conclusion A novel 8-element GA frailty score identified gradations in survival in patients declined for open heart surgery. Patients with higher GA frailty scores had significantly higher 2-year mortality after TAVI

A novel Geriatric Assessment frailty score predicts two-year mortality after Transcatheter Aortic Valve implantation.

Aims Established surgical scores have limitations in delineating risk among candidates for transcatheter aortic valve implantation (TAVI). Assessment of frailty might help estimate themortality risk and identify patients likely to benefit from treatment. The aim of the study was to develop a frailty score to guide the decision for TAVI. Methods and results We conducted a prospective observational study in patients ≥ 70 yearsreferred for TAVI during 2011-2015. A Heart Team had declined the patients for open heart surgery due to high risk but accepted them for TAVI. Prior to the procedure, a geriatric assessment (GA) was performed. Based on this, an 8-element frailty score with a 0-9 (least frail-most frail) scale was developed. A total of 142 patients, 54% women, mean age 83 (SD 4) years, with severe and symptomatic aortic stenosis were assessed. All-cause two-year mortality was 11%. The novel GA frailty score predicted two-year mortality in Cox analyses, also when adjusted for age, gender and logistic EuroSCORE (HR 1.75, 95% CI: 1.28-2.42, P < 0.001). A ROC curve analysis indicated that a GA frailty score cut-off at ≥ 4 predicted two-year mortality with a specificity of 80% (95% CI: 73%-86%) and a sensitivity of 60% (95% CI: 36%-80%). The area under the curve was 0.81 (CI 0.71-0.90). Conclusion A novel 8-element GA frailty score identified gradations in survival in patients declined for open heart surgery. Patients with higher GA frailty scores had significantly higher two-year mortality after TAVI