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Aarti Rao,1 Sandra M Shi,2,3 Jonathan Afilalo,4 Jeffrey J Popma,5 Kamal R Khabbaz,6 Roger J Laham,5 Kimberly Guibone,5 Edward R Marcantonio,2,7,* Dae Hyun Kim2,3,* 1Icahn School of Medicine at Mount Sinai, New York, NY, USA; 2Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 3Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; 4Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; 5Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 6Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; 7Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA*These authors contributed equally to this workCorrespondence: Dae Hyun KimHinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USATel +1 617-971-8320Fax +1 617-971-5339Email daehyunkim@hsl.harvard.eduBackground: Delirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction.Objective: To examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level.Design: Prospective cohort, 2014– 2017.Setting: Single academic center.Subjects: A total of 187 patients undergoing SAVR (n=77) or TAVR (n=110).Methods: The Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0– 12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium.Results: Delirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10– 12 (28.2%), 7– 9 (34.5%), 4– 6 (37.5%) and 0– 3 (44.1%) (p-for-trend=0.001). A model that included gait speed < 0.46 meter/second (OR, 2.7; 95% CI, 1.2– 6.4), chair stands time ≥ 11.2 seconds (OR, 3.5; 95% CI, 1.0– 12.4), MMSE < 24 points (OR, 2.9; 95% CI, 1.3– 6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1– 13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5– 45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035).Conclusion: Assessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.Keywords: delirium, physical performance, aortic valve replacement, prediction

Additional file 1: Table S1. Comprehensive Geriatric Assessment-Based Frailty Index. Figure S1. Distribution of Risk Index scores in Overall Cohort and by Procedural Cohort. Table S2. Association between standardized index scores and poor outcome at 12 months.