Steven R Messé1, Jessica R Overbey2, Vinod H Thourani3, Alan J Moskowitz2, Annetine C Gelijns4, Mark A Groh5, Michael J Mack6, Gorav Ailawadi7, Karen L Furie8, Andrew M Southerland9, Michael L James10, Claudia Scala Moy11, Lopa Gupta2, Pierre Voisine12, Louis P Perrault13, Michael E Bowdish14, A Marc Gillinov15, Patrick T O'Gara16, Maral Ouzounian17, Bryan A Whitson18, John C Mullen19, Marissa A Miller20, James S Gammie21, Stephanie Pan2, Guray Erus22, Jeffrey N Browndyke23. 1. Department of Stroke and Neurocritical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa. 2. International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. 3. Marcus Valve Center, Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Ga. 4. International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: Annetine.gelijns@mssm.edu. 5. Asheville Heart, Mission Health and Hospitals, Asheville, NC. 6. Cardiovascular Surgery, Baylor Scott & White Health, Plano, Tex. 7. Departments of Cardiac Surgery and Surgery, University of Michigan Health System, Ann Arbor, Mich. 8. Department of Neurology, Alpert Medical School of Brown University, Providence, RI. 9. Division of Vascular Neurology, University of Virginia Health System, Charlottesville, Va. 10. Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC. 11. Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md. 12. Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec, Canada. 13. Department of Surgery, Montreal Heart Institute, Québec, Canada. 14. Surgery and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif. 15. Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. 16. Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass. 17. Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, UHN-Toronto General Hospital, Toronto, Ontario, Canada. 18. Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio. 19. Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada. 20. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md. 21. Department of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Md. 22. Department of Radiology, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa. 23. Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC.
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.
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.