The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 167; no. 2; pp. 624 - 633.e4
• Main Authors: Overbey, Jessica R., Perrault, Louis P., Bowdish, Michael E., Gillinov, A. Marc, O'Gara, Patrick T., Whitson, Bryan A., Jeffries, Neal O., Buxton, Dennis, Smith, Tyrone, Gardner, Timothy J., Rose, Eric A., Parides, Michael K., Pan, Stephanie, Gupta, Lopa, O'Sullivan, Karen, Ye, Xia, Fenlon, Amanda, Johnson, Melissa, Miranda, Lucy, Ryan, William, Grayburn, Paul, Barzilai, Benico, Soltesz, Edward G., Garcia, Michelle, Takayama, Hiroo, Schwartz, Allan, DeSimone, Joseph P., DiScipio, Anthony W., Ivany, Amanda St, Smith, Peter K., Milano, Carmelo A., Glower, Donald D., Mathew, Joseph P., Johnson, Victoria, Englum, Brian, Thourani, Vinod H., Nguyen, Duc, Caouette, Manon, Tremblay, Hugo, Dumont, Julie, Landry, Patricia, Binns, Oliver A., Johnson, Alan M., Short, John G., Taylor, Reid D., Nanney, Tracy, Riggsbee, Christina, Michler, Robert E., Goldstein, Daniel J., Taub, Cynthia, Spevack, Daniel, Meli, Rebecca, Goldenberg, Jon, Tanguay, Jean François, Siegenthaler, Michael P., Greenberg, Ann, Kumkumian, Greg, Fadorsen, Denise, Farkouh, Michael, Woo, Anna, Cusimano, Robert James, Fumakia, Nishit, Christie, Shakira, Mullen, John C., Bissonauth, Asvina, Hripko, Alexandra, Gammie, James S., Collins, Julia, McDonald, Caitlin, Starnes, Vaughn A., Shavalle, David, Heck, Christi, Hackmann, Amy, Baker, Craig, Lozano, Edward, Ailawadi, Gorav, Johnston, Karen, Loya, Samantha, Bull, David A., Haigney, Mark, Holubkov, Richard, Meslin, Eric M., Murkin, John M., Spertus, John A., McDonald, Cheryl L., Williams, David O., Chaturvedi, Seemant, Fang, James C., Rao, Vivek, Han, Frederick, Pinney, Sean, Stapf, Christian, Zeng, Xin, Hung, David, Satitthummanid, Sudarat, Browndyke, Jeffrey N., Virmanu, Renu
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2024
• Subjects: Aftercare; aortic valve; Aortic Valve - surgery; Aortic Valve Stenosis - complications; Aortic Valve Stenosis - surgery; delirium; Delirium - diagnosis; Delirium - etiology; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - methods; Humans; neurological outcomes; Patient Discharge; perioperative management; Quality of Life; Risk Factors; Stroke - diagnosis; Stroke - etiology; surgical aortic valve replacement (SAVR); Transcatheter Aortic Valve Replacement; Treatment Outcome; NIHSS; aortic valve; CAM-ICU; perioperative management; MRI; 3D-CAM; SF-12; HR; IQR; SAVR; CAM; mRS; QoL; LOS; CTSN; STS; WAIS-3; neurological outcomes; delirium; surgical aortic valve replacement (SAVR)
• ISSN: 0022-5223; 1097-685X; 1097-685X
• DOI: 10.1016/j.jtcvs.2022.01.053

The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.
Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.
By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference −3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference −2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).
Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.
[Display omitted]