Masashi Takeuchi, Hideaki Suzuki, Yasuharu Matsumoto, Yoku Kikuchi, Kentaro Takanami, Toshihiro Wagatsuma, Jun Sugisawa, Satoshi Tsuchiya, Kensuke Nishimiya, Kiyotaka Hao, Shigeo Godo, Tomohiko Shindo, Takashi Shiroto, Jun Takahashi, Kiichiro Kumagai, Masahiro Kohzuki, Kei Takase, Yoshikatsu Saiki, Satoshi Yasuda ,Hiroaki Shimokawa
Abstract
Delirium is an important prognostic factor in postoperative patients undergoing cardiovascular surgery and intervention, including transcatheter aortic valve implantation (TAVI). However, delirium after transcatheter aortic valve implantation (DAT) is difficult to predict and its pathophysiology is still unclear. We aimed to investigate whether preoperative cerebral blood flow (CBF) is associated with DAT and, if so, whether CBF measurement is useful for predicting DAT.
Introduction
Aortic stenosis (AS) is the most common valvular heart disease in the elderly worldwide, leading eventually to angina, syncope, heart failure and sudden death along with gradual progression of valve calcification [1, 2]. As transcatheter aortic valve implantation (TAVI) is a well-established minimally invasive treatment, its target group is expected to be even older and high-risk patients with multiple diseases [3–5]. Delirium after TAVI (DAT) occurs especially in elderly patients [6] and is associated with poor long-term prognosis and increase in healthcare cost [7]. The prevalence of DAT is up to 44.0%, which is higher than that of postoperative delirium in surgical aortic valve replacement (SAVR) and other surgeries [8].
Materials and methods
Patient Enrollment
From January 2017 to February 2020, we enrolled consecutive 97 patients with severe AS who were candidates for TAVI in our Tohoku University Hospital. Severe AS was defined as an aortic-valve area of less than 0.8 cm2, a mean aortic-valve gradient of 40 mmHg or more, or a peak aortic-jet velocity of 4.0 m per second or more [4]. Before an acquisition of brain SPECT, 36 patients were excluded for the following reasons; emergent surgery (N = 2), New York Heart Association (NYHA) functional class [22] IV (N = 12), severe carotid artery stenosis (N = 2), psychiatric disorders (N = 3), cerebral aneurysm (N = 2), preoperative delirium (N = 1) and unavailability of brain SPECT scanning before TAVI (N = 14). After TAVI, 11 patients were excluded for the following reasons; postoperative heart failure and infection (N = 4), reintubation (N = 1), pacemaker insertion (N = 4) and postoperative hemorrhage (N = 2).
Results
The development of DAT was in 12 patients (24%) (Fig 1). The preoperative characteristics of the DAT and the non-DAT groups as shown in Table 1. The DAT group had significantly higher frailty (frailty index, 3.58±1.38 vs. 2.45±1.16, P = 0.007), lower cognitive function (MMSE, 20.67±4.58 vs. 25.22±3.65, P = 0.007) and lower physical function (SPPB, 6.58±3.15 vs. 8.78±3.24, P = 0.025). There was no difference between the two groups in age, sex, BMI, NYHA class, Charlson comorbidity index, Society of Thoracic Surgeons score, comorbidities, blood tests or echocardiographic and spirometric parameters (P>0.05).
Discussion
To support our hypothesis, the present study showed that preoperative CBF in the insula was significantly lower in patients with DAT than in those without it. Low CBF in the insula was raised as preoperative risk factor for DAT in addition to frailty, cognitive impairment and low physical function. The addition of insular CBF to these traditional preoperative risk factors increased an accuracy of the model predicting DAT with frailty index, MMSE and SPPB (AUC 0.882). To the best of our knowledge, this is the first report demonstrating that preoperative CBF of the insula is associated with the onset of DAT and may be useful to predict DAT in elderly patients with severe AS.
Conclusion
In the present study, we were able to demonstrate for the first time that reduced preoperative CBF in the insula assessed by SPECT is a useful predictor for postoperative development of delirium in patients with severe AS undergoing TAVI procedure.
Citation: Takeuchi M, Suzuki H, Matsumoto Y, Kikuchi Y, Takanami K, Wagatsuma T, et al. (2022) Prediction of the development of delirium after transcatheter aortic valve implantation using preoperative brain perfusion SPECT. PLoS ONE 17(11): e0276447. https://doi.org/10.1371/journal.pone.0276447
Editor: Antonino Salvatore Rubino, Cardiac Surgery Unit, Papardo Hospital, ITALY
Received: May 29, 2022; Accepted: October 7, 2022; Published: November 3, 2022
Copyright: © 2022 Takeuchi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because, based on the study protocol approved by the ethics committee of the Tohoku University Graduate School of Medicine (med-kenkyo@grp.tohoku.ac.jp)(No. 2018-1-567), the participants in this study were given written-informed consents, in which their data are not planned to be open to the public or to be shared with other researchers.
Funding: This work was supported by the Grants-in-Aid program from the Japan Society for the Promotion of Science (20K07776). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
