Non-transfemoral access is strongly associated with post-TAVI delirium


Masieh Abawi (Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands) and others report in JACC Cardiovascular Interventions that about 13% of patients develop postoperative delirium after undergoing transcatheter aortic valve implantation (TAVI). Furthermore, they write that non-transfemoral access is strongly associated with the condition.

The authors note that up to 31% of patients develop delirium after undergoing cardiac surgery and this figure increases with age—up to 66% of patients aged ≥70 years develop the condition. They add that patients undergoing operations that involve valve replacement “appear at higher risk of postoperative delirium than patients subjected to coronary artery bypass surgery alone” and that patients undergoing TAVI “seem particularly prone” to developing it. However, although delirium is known to increase mortality and is also associated with an elevated risk of dementia, according to Abawi et al, little evidence is available for the incidence of delirium after TAVI. “By means of this retrospective, descriptive study, we sought to investigate the incidence, predictive factors, and effect of postoperative delirium among patients treated with TAVI,” they write.

Reviewing data for 268 patients who underwent TAVI at the University Medical Center Utrecht, the authors found that 13.4% of patients had delirium (according to the criteria of the diagnostic and statistical manual of mental disorders-IV). Significantly more patients with delirium had undergone TAVI with non-transfemoral access compared with those without delirium: 50% vs. 10%, respectively; p

Furthermore, stroke, cardiac tamponade, postoperative atrial fibrillation, infectious disease, and acute kidney disease were all significantly higher among those with delirium than those without delirium.

After a median follow-up of 16 months, postoperative delirium was a significant predictor of mortality among patients who had undergone the transfemoral approach but not among those who had undergone a non-transfemoral approach, independent of age, sex, logistic EuroScore, and the occurrence of complications.

Abawi et al comment that the predictors identified in their study could aid in the “identification of TAVI patients who are higher risk for developing postoperative delirium and who will benefit most from intensified surveillance and targeted prevention.” They add that although many “predisposing and precipitating factors” are non-modifiable, several non-pharmacological measures can be taken to prevent postoperative delirium in susceptible patients.

The authors conclude: “Early recognition and prevention strategies may decrease the incidence of postoperative delirium and improve outcomes in TAVI patients. Future large prospective studies are needed to confirm these findings first on postoperative delirium after TAVI.”

Principal investigator Pieter Stella (head of Department of Interventional Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands) told Cardiovascular News: “A lot of our efforts to further improve our TAVI results in Utrecht are aimed at patient safety such as preventing stroke by using cerebral protection devices during all procedures and—in strong collaboration with our geriatric department—preventing post-operative delirium. We have introduced a pre-procedural screening programme for all patients and preventive measures as described in the manuscript are implied.”