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

Abstract

Objective: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Trial registration: ClinicalTrials.gov NCT02389894.

Keywords: aortic valve; delirium; neurological outcomes; perioperative management; surgical aortic valve replacement (SAVR).

Figure 1:

Legend: Panel A gives the model estimated means and 95%CIs for baseline-adjusted change in SF-12 between 90 days and baseline for those with and without clinically apparent stroke by day 7. Panel B gives the odds ratios and 95%CI for depression (Geriatric Depression Scale score >10), functional impairment (mRS >2 and Barthel Index ≤80), and neurocognitive decline (a 0.5 standard deviation decrease in overall neurocognition Z-score) at 90 days in patients with and without clinically apparent stroke by day 7. Odds ratios for depression and neurocognitive decline are adjusted for their corresponding baseline measures. Panels C and D depict the same for those with and without evidence of delirium by day 7. CI, confidence interval; mRS, modified Rankin Scale

Figure 2.

Legend: Incidence and 90-day impact of post-operative stroke and delirium after SAVR in the CTSN embolic protection trial. Stroke and delirium post-SAVR are common and have profound clinical effects including increased length of hospital stay after surgery and reduced functional status, quality of life, and neurocognition at 90 days post-op. These findings highlight needs for routine post-operative neurologic assessments to identify events and for neuroprotective treatments to reduce these events and improve patient-centered outcomes.

Central Picture Legend

Incidence and 90-Day Impact of Post-operative Stroke and Delirium after SAVR