Transcatheter aortic valve implantation (TAVI) is widely performed in elderly patients with severe aortic stenosis who are at high surgical risk. The incidence of delirium after TAVI has been reported to range from 12%-53%, and there have been several reports of risk factors for delirium after TAVI[1,2], however, there are few reports on how delirium is treated for such highly geriatric population.

 

Antipsychotics commonly used in the treatment of delirium carry the risk of various adverse drug events (ADEs), which are even higher in the elderly[3]. In recent years, dexmedetomidine (DEX) has been reported to be effective in the prevention and treatment of delirium[4].

We conducted a retrospective cohort study to determine the incidence of delirium after TAVI and pharmacological treatment including DEX and antipsychotics for delirium after TAVI in real-world practice. 

Study Design & Participants: This retrospective cohort study was conducted among all patients enrolled in the TAVI registry of the Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, who underwent TAVI between January 1, 2017, and December 31, 2020.

 

Data collection: Three psychiatrists evaluated the occurrence and duration of delirium after TAVI through a retrospective chart review. They also collected the information about comorbidities of patients, death after TAVI, and medication use for the delirium.

 

Outcome measures: The primary objective is the incidence of delirium after TAVI. The diagnosis of delirium is based on clinical assessment and is guided by Diagnostic Statistical Manual of Mental Disorders, fifth edition (DSM-5). Secondary objective was medication for the delirium. We also investigated the impact of delirium on all-cause mortality after TAVI.

 

This study was approved by the institutional review boards of the Kyoto Prefectural University of Medicine.

 

About Transcatheter aortic valve Implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) is a minimally invasive cardiac procedure that uses a catheter to replace a thickened aortic valve as a treatment for aortic stenosis.
TAVI may be an option for people at risk of complications from surgical aortic valve replacement.

[Atlas of Cardiac and Vascular Diseases for Informed Consent (TOA EIYO Co., Ltd.)]

About Dexmedetomidine (DEX)

 

Results (Analysis of 285 out of 392 total participants)

Patients Demographic and Outcome

Demographics and Outcomes (285 patients)

Outcomes

*1: CFS is a 9-point scale that quantifies frailty based on function in individual patients.

*2; The Society of Thoracic Surgeons (STS) score is a risk stratification model that is composed of up to 30 variables that predict short- and long-term mortality and morbidity after cardiac surgery.

Abbreviations: IQR, Interquartile Range, HR, Hazard ratios; CI, Confidencial Interbal; POD, Postoperative delirium; CFS, Clinical Frailty Scale, STS score, The Society of Thoracic Surgeons score

 

Drugs Used for POD patients (N=120)

Hazard ratios of all cause death from Cox proportional hazard models

This model included presence of POD, age (≥90), CFS (≥5), STS Score (≥8), presence of dementia, operation time ((≥120 min), use of DEX.

 

Discussion & Conclusions

In this study, DEX was widely used in patients undergoing TAVI with or without delirium, and the majority of delirium after TAVI was treated with DEX alone or DEX plus a non-antipsychotic psychotropic drug. The impact of DEX use on favorable life outcomes after TAVI may be due to the fact that DEX use reduced the use of psychotropic medications that have a high risk of causing a variety of ADEs. 

 

Reference

[1] Tilley et al. Meta-analysis of Prevalence and Risk Factor for Delirium After Transcatheter Aortic Valve Implantation. Am J Cardiol. 2018;122:1917-1923.

[2] Goudzwaard et al. Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation. Age Ageing. 2020;49:389-394.

[3] Gareri et al. Use of atypical antipsychotics in the elderly: a clinical review. Clin Interv Aging. 2014;9:1363-1373.

[4] Ng et al. The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis. Anesthesia. 2019;74:380-392.

 

This study was approved by the institutional review board of the authors’ institute, and there are no conflict of Interest in this study.

Corresponding Author: Nobutaka Ayani, M.D., Ph.D.  Email address: lingren@koto.kpu-m.ac.jp