Tse Lurdes, Bowering John B, Schwarz Stephan K W, Moore Randell L, Burns Kyle D, Barr Alasdair M
Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Medical Sciences Block C, 2176 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
Can J Anaesth. 2015 Jan;62(1):22-30. doi: 10.1007/s12630-014-0254-2. Epub 2014 Oct 22.
Transcatheter aortic valve implantation (TAVI) techniques show favourable survival outcomes in high-risk patients, but the incidence of postoperative delirium is unknown. We conducted a historical cohort study to compare postoperative delirium in retrograde transfemoral (TF) versus anterograde transapical (TA) TAVI procedures. We also sought to identify independent predictors of delirium following TAVI.
We performed a retrospective chart review on all patients who underwent TF (n = 77) or TA (n = 45) TAVI during 2008 and 2009 at St. Paul's Hospital (Vancouver, BC, Canada), the pioneering centre for these procedures. The primary outcome was a documented physician diagnosis of delirium. Abstracted data included information on demographics, medical history, surgical procedure, anesthesia, and postoperative care. We employed a multivariable logistic regression to identify independent predictors of delirium.
Delirium occurred in 12% of TF patients vs 53% of TA patients (P < 0.001). Preoperatively, the groups differed significantly in the rates of hypertension, pulmonary hypertension, dyslipidemia, peripheral vascular disease, congestive heart failure, previous myocardial infarction, and memory impairment. Differences in anesthetic management were also observed between the TF vs TA groups regarding inhalational anesthetics, opioids, neuromuscular blockers, antihemorrhagic drugs, and antibiotics. Independent predictors for delirium after TAVI included coronary artery disease (odds ratio [OR] 12.7; 95% confidence interval [CI] 1.0 to 154.9), cognitive impairment (OR 6.5; 95% CI 1.8 to 23.2), and cardiac arrhythmia (OR 3.5; 95% CI 1.1 to 11.6). Compared to the TF approach, TA-TAVI independently increased the risk of delirium (OR 13.8; 95% CI 3.3 to 59.0).
Patients undergoing TA-TAVI had a markedly increased incidence of postoperative delirium compared with patients undergoing TF-TAVI.
经导管主动脉瓣植入术（TAVI）技术在高危患者中显示出良好的生存结果，但术后谵妄的发生率尚不清楚。我们进行了一项历史性队列研究，以比较逆行经股动脉（TF）与顺行经心尖（TA）TAVI手术的术后谵妄情况。我们还试图确定TAVI术后谵妄的独立预测因素。
我们对2008年至2009年期间在圣保罗医院（加拿大不列颠哥伦比亚省温哥华）接受TF（n = 77）或TA（n = 45）TAVI的所有患者进行了回顾性病历审查，该医院是这些手术的先驱中心。主要结局是有记录的医生诊断的谵妄。提取的数据包括人口统计学、病史、手术过程、麻醉和术后护理等信息。我们采用多变量逻辑回归来确定谵妄的独立预测因素。
TF组患者谵妄发生率为12%，而TA组为53%（P < 0.001）。术前，两组在高血压、肺动脉高压、血脂异常、外周血管疾病、充血性心力衰竭、既往心肌梗死和记忆障碍的发生率方面存在显著差异。在TF组和TA组之间，在吸入麻醉药、阿片类药物、神经肌肉阻滞剂、抗出血药物和抗生素的麻醉管理方面也观察到差异。TAVI术后谵妄的独立预测因素包括冠状动脉疾病（比值比[OR] 12.7；95%置信区间[CI] 1.0至154.9）、认知障碍（OR 6.5；95% CI 1.8至23.2）和心律失常（OR 3.5；95% CI 1.1至11.6）。与TF方法相比，TA-TAVI独立增加了谵妄风险（OR 13.8；95% CI 3.3至59.0）。
与接受TF-TAVI的患者相比，接受TA-TAVI的患者术后谵妄发生率显著增加。
