Delirium Common, Costly After Mitral, Tricuspid Valve Repair

Delirium occurred in nearly 1-in-10 elderly patients after percutaneous mitral and tricuspid valve repair and signaled longer hospital stays and worse survival, a new study shows.

Mortality was nearly fourfold higher at 6 months among patients with postoperative delirium (POD) compared with those without (hazard ratio [HR], 3.84; P = .008).

Even after adjustment for EuroSCORE II, ejection fraction, hemoglobin, and frailty, delirium was an independent predictor of mortality (HR, 4.31; P = .017), according to a report published in the March 8 issue of JACC: Cardiovascular Interventions.

POD is a common complication, particularly in geriatric patients, and is targeted through a variety of interventions from preoperative cognitive and frailty screening to modified anesthesia and postoperative bedside testing.

Delirium after transcatheter or surgical aortic valve replacement (TAVR/SAVR) is known to be associated with longer hospitalization and worse survival, but data are lacking for the growing number of patients undergoing percutaneous treatment for mitral or tricuspid valve regurgitation. These patients often present at advanced age, frail, and with multiple comorbidities and, thus, are more prone to develop POD, observed lead author Maria I. Körber, MD, University of Cologne, Germany, in an interview.

The authors reported on 177 patients (median age, 78 years; range, 72 to 82), who underwent percutaneous mitral repair (n = 155), tricuspid repair (n = 12), or repair of both valves (n = 10) using the MitraClip, PASCAL, or Cardioband systems between November 2017 and May 2019. The procedures were performed using general anesthesia and either gas or intravenous propofol, and by transfemoral access.

Chronic renal insufficiency was the most common comorbidity (83%), followed by atrial fibrillation (76%), hypertension (74%), and coronary artery disease (58%). The median EuroSCORE II was 6%, 41.2% of patients presented as frail, and 42.4% presented as pre-frail. Patients with severe preprocedural cognitive impairment were excluded.

Postoperative delirium occurred in 9% of patients and was typically diagnosed on the first postoperative day (9/16 patients).

The 9% incidence is comparable to recent data in patients undergoing TAVR but may be low, as patients were systematically evaluated only on postoperative days 1 and 2, Körber suggested.

“If we were able to screen for 3 or 4 postinterventional days with clinically experienced nurses that are educated in screening delirium maybe we would even have found more to be honest,” she said. “I think it may be an underestimation, the 9%.”

In patients who developed postoperative delirium, hospital stay was longer (8 days vs 6 days; P = .01) and 30-day mortality 4 times higher (13% vs 3%; P = .126).

After 6 months, postoperative delirium was associated with worse survival (log rank P = .004), with 65% of patients who experienced delirium alive compared with 89% of those without delirium.

Although studies in TAVR patients have implicated general anesthesia and nonfemoral access as potential risk factors for POD, the researchers found no differences in patients with vs without delirium in terms of demographics, comorbidities, New York Heart Association functional class, type of intervention, or type of anesthesia (gas vs intravenous). Technical and procedural success rates were also similar between groups, although Körber noted that the sample size limited the statistical power to identify clinical predictors.

“It will be very important to have predictors for delirium because what we have as our main message is that delirium occurs quite often and, I strongly believe, has an impact on outcome,” she said.

Reached for comment, David A. Wood, MD, University of British Columbia, Vancouver, Canada, said, “It’s a small study, so it’s difficult to make practice-changing recommendations, but it’s very encouraging to see us measure delirium as a significant outcome in the mitral and tricuspid space.”

A proponent of minimalist TAVR, Wood said he hopes mitral and tricuspid procedures will be increasingly performed with minimal or no procedural sedation and 4-dimentional intracardiac ultrasound (ICE), which allows for hemodynamic assessment without the need to place a probe down the patient’s throat with IV sedation.

“If you can just put that [catheter] up the right atrium to guide your minimally invasive tricuspid and mitral valve repair or replacement and you don’t have to give a general anesthetic to these elderly patients with multiple comorbidities, that’s a huge quantum leap forward,” Wood said. “There are isolated centers globally doing a bit of that right now — just like 10 years ago there were isolated centers doing that for TAVR.”

The 3M TAVR study, which Wood led and featured the Vancouver 3M Clinical Pathway, used local anesthesia with no or minimal procedural sedation in 99% of cases and reported no POD, he pointed out. Registry data reported last year also showed a 15% reduction in mortality in patients who underwent TAVR with conscious sedation rather than general anesthesia.

“You’re going to see that type of practice emerge over the next couple of years in the mitral and tricuspid space, which I think is great for patients, it’s great for hospital resources, it’s great for the system,” Wood said.

Körber said there are excellent data for better outcomes after minimal sedation in TAVR but that they don’t use it for mitral or tricuspid patients because the procedures can take several hours. A shift to minimal sedation could be possible in a year or two for straightforward MitraClip or PASCAL mitral repairs but will take longer for tricuspid cases because of the complexity.

“At the moment, to be honest, everyone is done in general anesthesia and there is no clear trend that we would try to use mild sedation only for our cases,” she said. “But everything points into the direction that we should have earlier discharge, even less anesthesia and, if you look at our results, it could be very important as well.”

The study was funded by the German Heart Foundation. Körber has disclosed no relevant financial relationships. Wood reported research support from Edwards Lifesciences, Medtronic, and Abbott.

J Am Coll Cardiol Cardiovasc Interv. 2021;14:583-592. Full text

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