The Annals of thoracic surgery · 2026
Delirium after Aortic Arch Surgery with Hypothermic Circulatory Arrest: Clinical and Neuroimaging Insights from the GOT ICE Randomized Trial.
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Hughes G Chad, Browndyke Jeffrey N, Chen Edward P, Szeto Wilson Y, DiMaio J Michael, Brinkman William T, Markovic Jovan, Gaca Jeffrey G, Blumenthal James A, Karhausen Jorn A, James Michael L, Yanez David, Li Yi-Ju, Mathew Joseph P
Аннотация
BACKGROUND: Postoperative delirium (POD) is a complication of arch surgery with hypothermic circulatory arrest (HCA) and may contribute to long-term cognitive decline, but prospective data are limited. We examined its incidence, predictors, and neurocognitive and neuroimaging correlates.
METHODS: The Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest trial compared deep versus moderate hypothermia during elective arch repair. Delirium was assessed preoperatively and on postoperative days 1-3 using the Confusion Assessment Method. Thirty-day outcomes, cognition, quality of life, and resting-state functional magnetic resonance imaging at 4 weeks and 1 year were compared by POD status.
RESULTS: Of 269 patients with complete assessments, POD occurred in 34.6% and did not differ significantly between hypothermia groups (p=0.45). Patients with POD had higher stroke rates (9.7% vs 0.6%; p<0.001), prolonged ventilation (3.2% vs. 0%; p=0.017), and longer hospitalization (8.5 vs. 5.9 days; p<0.001). Affected patients had worse cognition and quality of life (p<0.001) at 30 days, with partial recovery at 1 year. Baseline imaging demonstrated reduced thalamo-cerebellar connectivity in patients who developed POD (p<0.01, p-FWE<0.05), with persistent abnormalities at 1-year. Higher baseline cognition and ejection fraction were protective against POD (OR<1), whereas longer antegrade cerebral perfusion time increased risk (OR 1.03; 95% CI, 1.005-1.05; p=0.019).
CONCLUSIONS: POD affects >one-third of patients after arch surgery with HCA and is associated with worse 30-day and 1-year cognitive outcomes with enduring imaging abnormalities. Reduced preoperative thalamo-cerebellar connectivity suggests a preexisting neural vulnerability, indicating that delirium may unmask rather than cause long-term cognitive decline.
METHODS: The Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest trial compared deep versus moderate hypothermia during elective arch repair. Delirium was assessed preoperatively and on postoperative days 1-3 using the Confusion Assessment Method. Thirty-day outcomes, cognition, quality of life, and resting-state functional magnetic resonance imaging at 4 weeks and 1 year were compared by POD status.
RESULTS: Of 269 patients with complete assessments, POD occurred in 34.6% and did not differ significantly between hypothermia groups (p=0.45). Patients with POD had higher stroke rates (9.7% vs 0.6%; p<0.001), prolonged ventilation (3.2% vs. 0%; p=0.017), and longer hospitalization (8.5 vs. 5.9 days; p<0.001). Affected patients had worse cognition and quality of life (p<0.001) at 30 days, with partial recovery at 1 year. Baseline imaging demonstrated reduced thalamo-cerebellar connectivity in patients who developed POD (p<0.01, p-FWE<0.05), with persistent abnormalities at 1-year. Higher baseline cognition and ejection fraction were protective against POD (OR<1), whereas longer antegrade cerebral perfusion time increased risk (OR 1.03; 95% CI, 1.005-1.05; p=0.019).
CONCLUSIONS: POD affects >one-third of patients after arch surgery with HCA and is associated with worse 30-day and 1-year cognitive outcomes with enduring imaging abnormalities. Reduced preoperative thalamo-cerebellar connectivity suggests a preexisting neural vulnerability, indicating that delirium may unmask rather than cause long-term cognitive decline.