Should transcatheter aortic valve replacement be the preferential treatment for patients at risk of post-operative delirium?

Keywords: :

• POD
• Post-operative delirium
• SAVR
• Surgical aortic valve replacement
• TAVR
• Transcatheter aortic valve replacement

Since its CE approval in 2007, transcatheter aortic valve replacement (TAVR) has become a common treatment for severe aortic valve stenosis in patients with high surgical risk, or in those without an option for open heart surgery. Technical improvements in TAVR devices and the growing experience of the implanters has led TAVR to become a very safe treatment option with comparable or even better outcomes for this patient group than those seen with other valve replacement procedures.

As the name suggests, the main problem with ‘open heart surgery’ is its invasiveness. Post-operative delirium (POD) is an often observed but neglected complication of surgical aortic valve replacement (SAVR) that is mainly caused by extracorporeal circulation. In addition, periprocedural cerebrovascular events increase the incidence of POD substantially.

Bestehorn and co-workers carefully analyzed retrospective data from 2013 in the German Aqua Registry1, a compulsory data collection of nearly 22,000 in-patient procedures in hospitals billing aortic valve replacements (AVRs) to the insurance system. Finally, 3407 intermediate risk patients (EuroScore 10–20), 771 patients with SAVR and 2636 patients with transfemoral TAVR were compared concerning the occurrence of POD with the need of therapy (POD-T). The analyses could prove for the first time that the risk of POD-T for patients with intermediate surgical risk is approximately three times higher after SAVR compared to transfemoral TAVR (12.8% vs 3.8%). POD-T was accompanied by significantly higher mortality until discharge in the SAVR group (5.1% vs 3.3%) and affected regular discharge negatively (64.8% vs 36.7%).

In summary, POD is a serious complication after AVR and can substantially influence the clinical outcome. As it occurs more often after SAVR, POD has to be taken into consideration as part of the therapeutic strategy for patients with intermediate surgical risk. Particularly for patients with predisposing risk factors for POD like advanced age, diabetes, predictable long operation time, history of cerebrovascular disease, atrial fibrillation and arterial disease2, TAVR could be an alternative with the potentially lowest risk.

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Declaration of funding

This editorial was not funded.

Declaration of financial/other relationships

A.M.K. has disclosed that he is a consultant to Edward Life Sciences.