Commentary: "Pumphead," revisited

Central MessageNeurocognitive decline can occur after cardiac surgery, and further study is needed. However, it should not deter most patients who can gain major benefits from cardiovascular operations.See Articles page 543. Neurocognitive decline can occur after cardiac surgery, and further study is needed. However, it should not deter most patients who can gain major benefits from cardiovascular operations. See Articles page 543. In 2003, Bruce Stutz, an accomplished science and environment writer, published an article in Scientific American titled “Pumphead.”1Stutz B. Pumphead.Sci Am. 2003; 289: 76-81Crossref PubMed Scopus (11) Google Scholar In it, he provided a balanced review of the evidence available at that time on the topic of neurocognitive decline (NCD) that can occur after cardiac surgery. Mr Stutz wrote from some personal experience, having undergone a mitral valve repair operation about 1 year previously, and having noted some changes in his own emotions, thinking, and processing for a period of time after surgery. One focus in his article was on factors associated with the “pump” itself, as off-pump coronary surgery was increasing and randomized trials that would include assessment of neurocognitive function were enrolling. So what have we learned over the subsequent 20 years? In this issue of the Journal, Stanley and Sellke2Stanley M.E. Sellke F.W. Neurocognitive decline in cardiac surgery patients: what do we know?.J Thorac Cardiovasc Surg. 2023; 166: 543-552Abstract Full Text Full Text PDF Scopus (1) Google Scholar supply a state-of-the-art review of the topic, documenting and analyzing the available literature on the prevalence, pathologic mechanisms, and potential treatment strategies of this important surgical complication. NCD is inconsistently defined, making comparisons among studies challenging, but measurable NCD may occur in 40% to 50% of patients early after cardiac surgery, and it may persist long-term in 2.5% or more. While multiple causes are implicated, microembolism, cerebral hypoperfusion, and systemic inflammation have garnered the most attention. A variety of risk factors have emerged, including greater burdens of atherosclerosis, previous stroke, diabetes, advanced age, and baseline cognitive impairment. Unfortunately, most risk factors cannot be altered before surgery. The authors also carefully review the existing evidence on treatments and prevention of NCD. Intraoperative interventions designed to maintain specific arterial blood pressure goals, rewarm more slowly from hypothermia, and avoid aortic manipulation seem to have merit, and strategies that avoid prolonged intubation and postoperative acute kidney injury are likely effective. Notably, off-pump surgery does not reliably reduce the incidence of NCD (as noted in results of the ROOBY (Randomized On/Off Cardiopulmonary Bypass) trial3Shroyer A.L. Grover F.L. Hattler B. Collins J.F. McDonald G.O. Kozora E. et al.On-pump versus off-pump coronary-artery bypass surgery.N Engl J Med. 2009; 361: 1827-1837Crossref PubMed Scopus (908) Google Scholar that was enrolling in 2003), so “pumphead” may not be an accurate characterization of this significant complication. And what about Bruce Stutz? How has he fared since his surgery and his analysis? I spoke with him via Zoom from his home in Brooklyn. Mr Stutz remains highly productive in his career and his life. He has served as an editor of Audubon magazine and editor-in-chief of Natural History magazine, and has lectured at the graduate school at New York University. He has published more than 200 articles on the environment and many facets of science, his work having appeared in the New York Times Magazine, Discover, onEarth, Conde Nast Traveler, and others. He speaks fondly of his family, including his children and grandchildren. Next year he plans to spend an extended period of time in the Iberian Peninsula studying and reporting on an emerging environmental catastrophe. Importantly, he has remained free of any symptoms of heart failure and enjoys a fully active lifestyle. There is more work to be done to expand our understanding of NCD and to work toward reducing the disabilities that it can cause. However, we must also remember that major cardiovascular operations also carry the ability to profoundly impact the lives of patients in so many positive ways. Neurocognitive decline in cardiac surgery patients: What do we know?The Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 2PreviewNeurocognitive decline (NCD) is common after patients undergo cardiac surgery and has important implications for acute and long-term clinical outcomes and patient quality of life.1 Patients with atherosclerotic cardiovascular disease have an increased risk of developing cognitive impairment or dementia simply as a comorbidity of their primary disease process.2-5 It is well documented that approximately 40% to 50% of patients who undergo cardiac surgery develop measurable NCD in the early postoperative period (Table 1)1,6,9-12,14-17 Critical questions for cardiothoracic surgeons are the degree of disability patients suffer as a result of this early NCD, whether patients can be identified before surgery using a biomarker or cerebral imaging, and whether there are any interventions that could decrease that risk. Full-Text PDF