Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis

Aims: To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). Methods: We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. Results: A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73). Conclusions: POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.