1. Postoperative Delirium is Associated with Increased Operative and One Year Mortality in Patients Treated with Surgical and Transcatheter Aortic Valve Replacement Hersh Maniar MD, Brian Lindman MD, Michael Avidan MD, Krisztina Escallier Eric Novac, Marci Damiano, John Lasala MD, Marc Moon MD Spencer Melby MD, Nishath Quadar MD, Michael Pasque MD Ralph Damiano MD, Alan Zajarias MD Divisions of Cardiology and Cardiothoracic Surgery Washington University School of Medicine St. Louis, MO

2. Postoperative Delirium Postoperative delirium (PD) is a well recognized complication after cardiac surgery affecting up to 50% of patients PD has been associated with increased perioperative morbidity, hospital length of stay and perioperative mortality resulting in increased health care costs. Treatments for PD have had limited success and greater emphasis has been placed upon identifying high risk patients and prevention

3. Transcatheter Aortic Valve Replacement Increasingly adopted among high risk patients that are also at high risk for developing PD. Several high profile randomized trials have been performed comparing surgical aortic valve replacement (SAVR) to transcatheter aortic valve replacement (TAVR). None have addressed whether utilization of TAVR has impacted the incidence of PD or its associated negative outcomes.

4. Study Outline Evaluate the incidence of PD after TAVR and SAVR, examine adverse outcomes associated with PD and explore risk factors for the development of PD after either procedure 427 patients underwent either TAVR (n=168) or SAVR (n=159) for isolated severe aortic stenosis PD was assessed by the Confusion Assessment Method for the ICU (CAM-ICU). Perioperative outcomes and one-year mortality were evaluated in patients with and without PD

5. CAM-ICU (1) Change from baseline (2) Inattention (3) Disorganized thinking (4) Altered level of consciousness Performed in conjunction with the Richmond Agitation Sedation Scale (RASS) Performed twice daily on intubated/awake patients 90% specificity and 70% sensitivity

6. TAVR and SAVR Demographics TAVR (n=168)SAVR (n=259)p value Age81± 871 ± 11<0.001 Female92 (55%)108 (42%)0.010 BMI27.5 ± 6.331 ± 8<0.001 STS-PROM9.3 (6.1,13.5)3.0 (1.5,6.0)<0.001 ASA class ≥ 4162 (96%)180 (70%)<0.001 NYHA 3 or 4147 (88%)139 (54%)<0.001 DM72 (43%)95 (37%)0.22 HTN156 (93%)209 (81%)<0.001 CAD143 (85%)114 (44%)<0.001 CVD52 (31%)57 (22%)0.04 AF65 (39%)49 (19%)<0.001 CLD (moderate/severe)59 (35%)39 (15%)<0.001 PVD113 (67%)71 (27%)<0.001 EF (%)53 ± 1558 ± 140.002 Aortic Valve Gradient (mean)44 ± 1443 ± 140.70 Preoperative GFR64.1 ±26.774.9 ± 25.9<0.001 Hemoglobin11.3 ±1.512.5 ± 1.9<0.001 Albumin4.0 ± 0.54.1 ± 0.40.12

7. Delirium Incidence in TAVR and SAVR PD was identified in 32% of patients (n=135) AVR typePD (%) SAVR33% TAVR29% Transaortic/Tranaspical35% Transfemoral (TF)18% PD was hypoactive (RASS <0) 53% p=0.4 p=0.02

8. Delirium Incidence in TAVR and SAVR PD was identified in 32% of patients (n=135) AVR typePD (%) SAVR33% TAVR29% Transaortic/Tranaspical35% Transfemoral (TF)18% PD was hypoactive (RASS <0) 53% p=0.03

9. Perioperative Complications TAVRSAVR No Delirium (n=119) Delirium (n=49) p value No Delirium (n=173) Delirium (n=86) p value Prolonged ventilation 2 (2%)0 (0%)1.010 (6%)18 (21%)<0.001 Stroke 1(1%)1 (2%)0.51(1%) 1.0 Acute Kidney Injury 8 (7%)12 (24%)0.00325(14%)15(17%)0.003 Hospital length of stay 57<0.00179 Initial ICU stay (hours) 2650<0.0013172<0.001 Readmission to the ICU 4 (3%)5 (10%)0.122 (1%)9 (10%)0.001 Discharged to home 87 (73%)26 (53%)0.018146 (84%)49 (57%)<0.001 30 day survival 98%88%0.029100%95%0.04

10. Delirium and Survival

11. Delirium and One Year Mortality Interaction between AVR type (TAVR vs. SAVR) and PD with respect to 1-year mortality (interaction p=0.12). The relationship between PD and post-AVR mortality was similar for TAVR and SAVR treated patients. VariableHR95% CIp-value Delirium (yes)3.023(1.748, 5.228)<.001 TAVR (yes)2.360(1.269, 4.389)0.007 Age (per 1 year)1.006(0.976, 1.036)0.71 Female (yes)0.580(0.329, 1.023)0.06 STS score (per 1 unit)1.099(1.054, 1.146)<.001

12. Summary PD is common after TAVR and SAVR occurring in nearly a third of patients TAVR-TF had the lowest incidence of PD when compared to any other procedure PD was associated with increased perioperative morbidity and mortality PD is associated with a 3-fold increase in mortality during the first year after valve replacement

13. Conclusion Given the high incidence of PD and its adverse consequences, further studies should be performed to confirm and extend these findings. Identify modifiable risk factors for PD to minimize PD occurrence and improve short term outcomes Whether reducing PD will improve longer term outcomes remains to be determined

14. Thank you for your attention