Transcatheter aortic valve replacement (TAVR) is associated with a lower risk of postoperative delirium (PD) than surgical aortic valve replacement (SAVR) in patients aged ≥80, based on billing codes.• Postoperative delirium remains a frequent problem after both SAVR and TAVR in clinical series and is costly.• Improved pre-procedural prediction of PD risk would improve targeting of clinical care and allow testing of preventative and management strategies.Examining Medicare patients over the age of 80, transcatheter aortic valve replacement (TAVR) was less likely to generate a billing code for delirium (1.6%) than surgical aortic valve replacement (SAVR) at 3.6% (p < .0001) in Potter's study. 1 This occurred despite the TAVR patients being older with greater comorbidities, perhaps heralding another improvement in outcome with TAVR compared to SAVR. Yet postoperative delirium (PD) remains an important and difficult clinical problem for both approaches. In patients over 65 years of age undergoing cardiac surgery, postoperative delirium has a reported incidence of 26 to 52%.The estimated incremental cost of PD after cardiac surgery is 150 billion dollars annually in the United States. 2 TAVR patients had 29% incidence of PD in the best study to date. 2 PD is associated with significantly longer hospitalizations, costs, and mortality. While yielding some comparative insight, billing code ascertainment of PD undoubtedly significantly underestimates its incidence. Prospective studies suggest only one in four patients with delirium (particularly hypoactive or "quiet" delirium) were clinically recognized and/or addressed. The causes of PD are multiple with predisposing baseline factors and acute precipitants. 3 These include generalized frailty, preoperative cognitive impairment, and cerebrovascular disease with severe white matter hyperintensities on preoperative MRI. Precipitants include anesthetic technique, pain control medicines, and perhaps inflammation. Particularly with increasing application of TAVR to older patients with greater frailty, a renewed and concerted effort to improve preprocedural TAVR (and SAVR) PD prediction is warranted. 4 Preoperative prediction would permit targeting resources for both clinical care and further research. Minimalist TAVR without general anesthesia may be an effective strategy to reduce PD. Other promising strategies such as better-tolerated pain control regimens(as recently demonstrated with IV acetaminophen after cardiac surgery) should be tested surrounding TAVR. 5 While this study seems to be another "win" for TAVR versus SAVR in some immaterial scorecard, postoperative/post-procedural delirium remains a significant, seemingly intractable problem as we address ever-frailer and sicker patients with structural heart diseases.
ORCIDWilliam B. Hillegass https://orcid.org/0000-0001-6428-0564 REFERENCES 1. Potter BJ, Thompson C, Green P, Clancy S. Incremental cost and length of stay associated with post-procedure delirium in transcatheter and surgical aortic valve replacement patien...