Thoracic Surgery Research Articles

Atrial Fibrillation Surgery in Australia: Are We Doing Enough?

This study aimed to examine contemporary burden and treatment trends of atrial fibrillation (AF) in patients undergoing cardiac surgery in Australia and New Zealand. This allows comparison of contemporary practice with the Society of Thoracic Surgeons guideline recommendations for the surgical treatment of AF in patients undergoing cardiac surgery. A 10-year retrospective review of the Australian & New Zealand Society of Cardiac & Thoracic Surgeons National Cardiac Surgery Database was performed, examining all adult cardiac surgery patients from 2011 to 2021. Patients were grouped by the presence or absence of AF, and simple descriptive statistical analysis was performed to assess baseline demographics and premorbid condition of the patients. The incidence of AF was analysed by type of surgery. Trends for surgical treatment of AF were then analysed using simple descriptive statistics, examining isolated left atrial appendage ligation, isolated surgical ablation, and combined ligation and ablation. In the last 10 years, the Australian & New Zealand Society of Cardiac & Thoracic Surgeons database has recorded 140,680 patients who underwent cardiac surgery. Atrial fibrillation (AF) was present in 21,077 patients (14%). Patients with AF were generally older (72.25 vs 66.65 years; p<0.001). Among patients undergoing cardiac surgery, AF was more common in female than in male patients (18% vs 13%, respectively). Patients with AF more often had a higher classification of dyspnoea according to the New York Heart Association and lower ejection fractions compared with their AF-free counterparts. The incidence of AF as a comorbid condition was more frequent in patients undergoing mitral valve surgery or combined coronary artery bypass grafting and valve surgery (aortic, mitral, or both) compared with those undergoing isolated coronary or aortic surgery. Only 11.90% (n=2,509) of patients with AF received a combined ablation and left atrial appendage ligation, and 19.54% (n=693) of those received a Cox-Maze IV ablation. The burden of concomitant AF in patients undergoing cardiac surgery in Australia is higher than previously reported (14% vs 5%-11%). Despite strong recommendation for the surgical management of AF in patients undergoing cardiac surgery and clear evidence of its benefit, both left atrial appendage ligation and surgical ablation independently or concomitantly remain heavily underutilised in this cohort.

Long Term Impact of Regionalization of Thoracic Oncology Surgery

In 2007, Cancer Care Ontario created Thoracic Surgical Oncology Standards for the delivery of surgery including lobectomy, esophagectomy and pneumonectomy. These standards regionalized thoracic surgery into designated centers and mandated physical and human resources. This analysis seeks to identify the impact of these standards, hereafter referred to as "regionalization", on outcomes after thoracic oncology surgery in Ontario, Canada. Population-level analysis of patients undergoing lobectomy, esophagectomy or pneumonectomy, using multi-level regression models to compare 30- and 90-day mortality and length of stay length of stay, before, during and after regionalization. Interrupted time series models were used to assess for an impact of regionalization, controlling for ongoing trends. A total of 22,195 surgeries (14,902 lobectomies, 4,958 esophagectomies, and 2,408 pneumonectomies) were performed within the study period. >99% of cases were performed at a designated center post-regionalization. Mean annual volumes per designated center increased post-regionalization for lobectomy and esophagectomy, and decreased for pneumonectomy. 30- and 90-day mortality and length of stay improved for lobectomy and esophagectomy over the study period, as did 90-day mortality for pneumonectomy. However, the interrupted time series analysis did not demonstrate any statistically significant effect of regionalization on these outcomes, separate from pre-existing trends. Consistent improvements in mortality and length of stay in thoracic surgical oncology occurred on a provincial level between 2003-2020, although this analysis does not attribute these improvements to implementation of Thoracic Surgical Oncology Standards including regionalization.

Development of a Novel Society of Thoracic Surgeons Aortic Surgery Mortality and Morbidity Risk Model

The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) was expanded in 2017 to include more granular detail on thoracic aortic surgeries. We describe the first validated risk model in thoracic aortic surgery from the STS-ACSD. The study population consisted of patients undergoing non-emergent isolated ascending aortic aneurysm repair using open or clamped distal anastomoses, including those requiring aortic root or valve replacement. Model outcomes included operative mortality, 30-day major morbidity (cardiac reoperation, deep sternal wound infection, stroke, prolonged ventilation, renal failure) and a composite of both. To select the predictors, univariate associations and clinical face validity of models were examined. Models were evaluated by their ability to distinguish between patients with and without specific outcomes (discrimination) and their predictive accuracy (calibration). Between 2017 and 2021, 24,051 eligible patients underwent ascending aortic aneurysm surgery at 905 hospitals. Procedures included 8,913 aortic root replacements, 2,135 valve-sparing root replacements, 7,545 ascending aortic replacements with AVR, and 5,458 ascending aortic replacements. Circulatory arrest was performed in 7,316 (30.4%) of cases. Operative mortality was 1.9%, and 12.2% of patients experienced major morbidity including 2.4% incidence of stroke. The adjusted C-statistics for the model were 0.74, 0.67 and 0.67 for mortality, morbidity and the composite, respectively. Previous stroke and circulatory arrest were associated with new stroke. Genetic aortopathy was associated with less mortality. A new STS-ACSD risk model to predict mortality and morbidity after ascending aneurysm surgery has been developed, and predictors of better and worse outcomes have been identified.

A pilot project to explore the mental health and wellbeing among cardiothoracic staff and the impact of virtual reality guided mindfulness

BackgroundThe Cardio-Thoracic (CT) professional group experienced a significant increase in stress and workload during and after the COVID-19 pandemic. The Society for Cardiothoracic Surgery (SCTS) in Great Britain and Ireland with the aim of endorsing positive change. Aim of this project was to understand the Mental Health (MH) and wellbeing status of the CT professionals and to explore Virtual Reality Mindfulness as an intervention to improve MH and wellbeing.MethodsIn February 2022, the SCTS created a Mental Health and Wellbeing Working Group to identify the problem and find solutions. This exploratory project was carried out in two stages. Stage one was an online survey conducted in March 2022 and stage two was a Virtual Reality (VR) mindfulness workshop in March 2023, using the Rescape™ VR mindfulness tool.ResultsStage one: An online QR code survey was sent out to 150 members with 129 (86%) completed responses. 92% expressed that SCTS should create awareness about mental health and wellbeing. 99% said that they should be allowed to speak up and create interventions for members to access, support and relax. Three main themes identified about why CT staff do not discuss their Mental Health problems were fear of lack of awareness (72%), lack of confidentiality (60%) and impact on career (60%). Stage two: 88 members attended the VR session of which 76 (86%) completed the anonymous questionnaire. 97% reported usage was a pleasurable experience, 91% felt more relaxed, 82% felt less stressed, 90% felt calmer and 89% had their mood enhanced.ConclusionOur study findings indicate that CT staff experience considerable effects on their mental health and wellbeing. However, there is a hesitancy to recognise and seek assistance due to concerns about confidentiality and career repercussions. The virtual reality mindfulness session served as a beneficial supplement, with a positive impact in this pilot cohort.

Three-dimensional printed titanium chest wall reconstruction for tumor removal in the sternal region

Resection of thoracic wall tumors results in significant defects in the chest wall, leading to various complications. In recent years, the use of three-dimensional (3D) printed titanium alloy prostheses in clinical practice has demonstrated enhanced outcomes in chest wall reconstruction surgery. A cohort of seven patients with sternal tumors was identified for this study. Following a helical CT scan, a digital model was generated for the design of the prosthesis. Subsequently, the tumors were then removed together with the affected sternum and ribs. The chest wall was then reconstructed using 3D-printed titanium alloy prosthesis for bone reconstruction, mesh for pleural reconstruction, and flap for soft tissue reconstruction. Patients were monitored for a period of one year post-surgery. In the seven cases examined, the tumors were found in various locations with varying degrees of invasion. Based on the scope of surgical resection and the size of the defect, 3D-printed titanium alloy prosthesis was custom-designed for chest wall reconstruction. Prior to bone reconstruction, pleural reconstruction was achieved with Bard Composix E/X Mesh, while soft tissue repair involved muscle flap and musculocutaneous flap procedures. A one-year follow-up assessment revealed that the utilization of the 3D-printed titanium alloy prosthesis led to secure fixation, favorable histocompatibility, and enhanced lung function. The findings demonstrate that the utilization of 3D printed titanium alloy prostheses represents a significant advancement in the field of chest wall reconstruction and thoracic surgical procedures.

Women in Cardiothoracic Surgery: Impact on Partners, Co-Parents, and Children

Women in Cardiothoracic Surgery: Impact on Partners, Co-Parents, and Children

Cardiothoracic surgery and white elephants in the room: medical neoliberalism and its consequences for patient care.

Cardiothoracic surgery and white elephants in the room: medical neoliberalism and its consequences for patient care.

Implementing a Global Mentoring Program: A Call to Action for Mentorship in Surgery

BackgroundThe Gender Equity Initiative in Global Surgery organization launched a mentorship program to address the limited opportunities available in low-and-middle-income countries (LMICs). We aimed to evaluate the utility of the virtual program in bridging this critical gap. MethodsA retrospective review of program surveys containing quantitative and qualitative questions from 2022-2023 was performed. ResultsOf n=193 applicants, 81.3% (157/193) identified as women, and 69.4% (134/193) reported no prior mentorship. Applicants were from 41 countries (35 LMICs). The most requested specialties were general surgery (27.9%, 54/193), neurosurgery (18.1%, 35/193), and cardiothoracic surgery (11.4%, 22/193). 55.9% (108/193) preferred mentors from other countries (United States, United Kingdom, Canada), while 13.9% (27/193) preferred mentors from their country. Ultimately, 48 applicants were matched with 13 mentors. ConclusionsDemand for the program surpassed capacity, highlighting a need for mentorship opportunities for women overall, particularly in LMICs.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2024

This special article is the seventeeth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2024 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2024 begin with an update on perioperative rehabilitation and enhanced recovery (ERACS) in in cardiothoracic surgery, with a focus on novel methods to best assess our patients in the preoperative period and the impact of implementing enhanced recovery care models on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into anemia, transfusions, and CABG outcomes with a focus on gender disparities. The third theme is focused on cardiothoracic transplantation, with discussions focusing on techniques related to lung transplantation including MCS. The fourth theme is focused on mechanical circulatory support, with discussions exploring advancements in left ventricular assist devices (LVADs) highlight the evolving landscape of mechanical circulatory support and discussion of anticoagulation practices. The fifth, and final theme is an update on medical cardiology, with focus on outcomes of transcatheter management of regurgitant pathology, device management in heart failure, and new techniques in catheter ablation. The themes selected for this article are only a few of the diverse advances in the specialty during 2024. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Certification system for multidisciplinary thoracic tumour boards.

In Spain, lung cancer (LC) is the fourth most common cancer. Managing LC involves different professionals, and cooperative and coordinated work is crucial. Therefore, important decisions are better made by Multidisciplinary Thoracic Tumour Boards (MTTBs). On the other hand, certification systems have proven to improve the structure of care, ultimately having a positive impact on patient survival. Herein, a multidisciplinary working group of 11 experts (a Radiologist, a Thoracic Surgeon, a Pulmonologist, a Radiotherapy Oncologist, four Medical Oncologists, a Hospital Managing Director, a Cytologist, and a Molecular Biologist specialist) proposed a standard to certify and evaluate MTTBs. The following components were suggested for the standard: minimum requirements for the MTTB, a mixed model developed in two stages (preparation and audit), a structure comprising three groups of indicators (Strategic and Management, Support, and Operational), three certification levels, and an audit process. In our opinion, certifying MTTBs is critical to improve the standard of care for LC patients.

Time is Money: The Return on Investment of Research in Surgical Training: Brief Title: The ROI of Research in Surgical Training

IntroductionFuture income potential can impact surgical trainees’ career choices, particularly when deciding to subspecialize, which often requires additional training and research time. This study quantifies the effects of added time on career value for eight surgical subspecialties. MethodsThe Net present value(NPV) was calculated for eight subspecialties and general surgery over a 35-year career, factoring in salary, educational debt, tax, inflation, and practice setting. NPV for each was compared over a number of research years (0, 1, 2) using data from the MGMA, AAMC, and US government records. ResultsAfter a 35-year career, six subspecialties in private practice increased career NPV(>$14,000) with 0 research years. One additional research year yielded negative career values for transplant, trauma, and vascular; with two, only cardiovascular and pediatric retained a positive NPV. In academia, 1-2 research years resulted in negative NPV for all but cardiovascular and thoracic surgery. ConclusionsThe financial return of additional training years is highly variable.

Safety and efficacy of thrombolytic therapy in the treatment of early pulmonary embolism after thoracic surgery

Safety and efficacy of thrombolytic therapy in the treatment of early pulmonary embolism after thoracic surgery

Estimated impact of a tobacco-elimination strategy on lung-cancer mortality in 185 countries: a population-based birth-cohort simulation study

The tobacco-free generation aims to prevent the sale of tobacco to people born after a specific year. We aimed to estimate the impact of eliminating tobacco smoking on lung-cancer mortality in people born during 2006-10 in 185 countries. For this population-based birth-cohort simulation study, we proposed a scenario in which tobacco sales were banned for people born between Jan 1, 2006, and Dec 31, 2010, and in which this intervention was perfectly enforced, quantified until Dec 31, 2095. To predict future lung-cancer mortality rates, we extracted lung-cancer mortality data by sex, 5-year age group, and 5-year calendar period for countries with at least 15 years of data from the WHO Mortality Database. For countries for which mortality data were not available, we extracted data on lung-cancer incidence from the Cancer Incidence in Five Continents. To establish the number of lung-cancer deaths that could be prevented in the birth cohort if tobacco smoking was eliminated, we subtracted reported age-specific rate of deaths in people who had never smoked tobacco (hereafter referred to as never smokers) from a previous study from the expected rate of lung-cancer deaths in our birth cohort and applied this difference to the size of the population. We computed population impact fractions (PIFs), the percentage of lung-cancer deaths that could be prevented, by dividing the number of preventable lung-cancer deaths by the expected lung-cancer deaths in the birth cohort. We also aggregated expected and prevented deaths into the four World Bank income groups (ie, high-income, upper-middle-income, lower-middle-income, and low-income). The primary outcome was the impact on lung-cancer mortality of implementing a tobacco-free generation. Our birth cohort included a total population of 650 525 800 people. Globally, we predicted that 2 951 400 lung-cancer deaths could occur in the population born during 2006-10 if lung-cancer rates continue to follow trends observed during the past 15 years. Of these deaths, 1 842 900 (62·4%) were predicted to occur in male individuals and 1 108 500 (37·6%) were expected to occur in female individuals. We estimated that 1 186 500 (40·2%) of 2 951 400 lung-cancer deaths in people born during 2006-10 could be prevented if tobacco elimination (ie, a tobacco-free generation) was achieved. We estimated that more lung-cancer deaths could be prevented in male individuals (844 200 [45·8%] of 1 842 900 deaths) than in female individuals (342 400 [30·9%] of 1 108 500 deaths). In male individuals, central and eastern Europe had the highest PIF (48 900 [74·3%] of 65 800 deaths) whereas in female individuals, western Europe had the highest PIF (56 200 [77·7%] of 72 300 deaths). Middle Africa was the region with the lowest PIF in both male individuals (180 [2·1%] of 8600 deaths) and female individuals (60 [0·9%] of 6400 deaths). In both sexes combined, PIF was 17 400 (13·5%) of 128 900 deaths in low-income countries, 104 900 (15·8%) of 662 800 deaths in lower-middle-income countries, 650 100 (43·9%) of 1 482 200 deaths in upper-middle-income countries, and 414 100 (61·1%) of 677 600 deaths in high-income countries. The implementation of a tobacco-free generation could substantially reduce global lung-cancer mortality. However, data from low-income countries were scarce and our estimates should be interpreted with caution. Spanish Society of Pneumology and Thoracic Surgery.

Real-Time Ultrasonography for the Placement of Caudal Epidurals for Thoracic Surgery in Infants: A Description of the Technique and Case Series.

Caudal epidural catheters threaded to the thoracic levels are increasingly utilized in infants undergoing thoracic and abdominal surgery, compared to lumbar or thoracic epidural techniques. Estimating catheter length traditionally relies on anatomical landmarks, but the lack of spine ossification in infants makes ultrasonography a valuable and noninvasive tool. We present 3 cases where real-time ultrasonography facilitated caudal to thoracic epidural catheter placement in infants undergoing thoraco-abdominal surgeries. Incision-congruent placement of the catheter tip ensured effective perioperative analgesia with low doses of bupivacaine administered as intermittent boluses resulting in potent and prolonged analgesia with reduced opioid requirements.

Opioid use in thoracic surgery: a retrospective study on postoperative complications

Opioid use in thoracic surgery: a retrospective study on postoperative complications

Comparison of Long-Term Survival Between Robotic and Video-Assisted Lobectomy for Stage Ⅰ NSCLC With Radiologic Solid Tumors: A Propensity Score Matching Study

BackgroundTo compare the long-term survival between robotic and video-assisted thoracic surgery (VATS) lobectomy for stage Ⅰ non–small-cell lung cancer (NSCLC) with radiologic solid tumors. MethodsClinical stage Ⅰ NSCLC patients with radiologic solid tumors who underwent robotic-assisted thoracic surgery (RATS) or VATS lobectomy between 2015 and 2017 were retrospectively reviewed. A propensity score matching analysis was performed to balance the baseline characteristics. The primary end points were overall survival (OS) and recurrence-free survival (RFS). ResultsA total of 518 patients (225 RATS and 293 VATS) were included. After propensity score matching, there were 170 cases in each group. Patients undergoing RATS had shorter operative time than VATS (98.12 min vs. 112.26 min; p < 0.001). The RATS approach resulted in a higher number of resected lymph nodes (LNs) (11.75 vs. 9.77; p < 0.001). The postoperative complication rates were comparable (7.6% vs. 10.0%, P = .566). The rates of 5-year OS and RFS for the RATS and VATS were 92% versus 89% (P = .62) and 82% vs. 86% (P = .70), respectively. Multivariate analysis revealed that the number of resected LNs was significantly associated with overall survival (OR = 1.94 [95% confidence interval [CI]: 1.07-3.51], P = .029). ConclusionThe long-term survival outcomes of RATS and VATS are similar for c-stage Ⅰ NSCLC with radiologic solid tumors. The use of robotics is associated with more lymph node dissection and shorter operative time. We suggested that the number of examined lymph nodes rather than surgical approaches was associated with overall survival.

The role of prehabilitation in reducing the incidence of postoperative pulmonary complications in patients undergoing elective cardiac surgery: Results from the Pre Surgery Check Team study.

Despite its importance, prehabilitation, has only been implemented in very few cardiac surgery centers. The Pre Surgery Check Team study was designed to evaluate the impact of comprehensive interdisciplinary assessment and implementation of the prehabilitation program on the incidence of postoperative pulmonary complications after elective cardiac surgery. 725 adult patients (338 in the study group, 387 in the control group) were included in this single-center, prospective, observational study. Multimodal prehabilitation consisted of four elements: interdisciplinary medical assessment by cardiologist, anesthesiologist and cardiac surgeon, pulmonary assessment for patients at high risk of postoperative pulmonary complications, psychological assessment, and physiotherapeutic assessment and training. The primary endpoint was the occurrence of the postoperative pulmonary complications, and the secondary outcomes were: surgical site infection, rethoracotomy, ICU length of stay and hospital length of stay. Prehabilitation reduced the number of postoperative complications by 23%. Postoperative pneumonia was almost 3 times less common (5.33% vs 14.21%), and the surgical site infection - 1.4 times less common in the PreScheck group (8.28 vs 11.37%). In the logistic regression model, prehabilitation reduced the odds of postoperative pneumonia (by 0.346) and the odds of respiratory failure (by 0.479). Prehabilitation had no direct effect on ICU length of stay. Prehabilitation according to the Pre Surgery Check Team standard reduces the incidence of postoperative pulmonary complications and the total number of postoperative complications in patients undergoing elective cardiac surgery. The main benefit of attending the PreScheck Team visit is the opportunity to perform supportive preoperative interventions.

Early heart disease prediction using feature engineering and machine learning algorithms

Heart disease is one of the most widespread global health issues, it is the reason behind around 32 % of deaths worldwide every year. The early prediction and diagnosis of heart diseases are critical for effective treatment and sickness management. Despite the efforts of healthcare professionals, cardiovascular surgeons and cardiologists' misdiagnosis and misinterpretation of test results may happen every day. This study addresses the growing global health challenge raised by Cardiovascular Diseases (CVDs), which account for 32 % of all deaths worldwide, according to the World Health Organization (WHO). With the progress of Machine Learning (ML) and Deep Learning (DL) techniques as part of Artificial Intelligence (AI), these technologies have become crucial for predicting and diagnosing CVDs. This research aims to develop an ML system for the early prediction of cardiovascular diseases by choosing one of the powerful existing ML algorithms after a deep comparative analysis of several. To achieve this work, the Cleveland and Statlog heart datasets from international platforms are used in this study to evaluate and validate the system's performance. The Cleveland dataset is categorized and used to train various ML algorithms, including decision tree, random forest, support vector machine, logistic regression, adaptive boosting, and K-nearest neighbors. The performance of each algorithm is assessed based on accuracy, precision, recall, F1 score, and the Area Under the Curve metrics. Hyperparameter tuning approaches have been employed to find the best hyperparameters that reflect the optimal performance of the used algorithms based on different evaluation approaches including 10-fold cross-validation with a 95 % confidence interval. The study's findings highlight the potential of ML in improving the early prediction and diagnosis of cardiovascular diseases. By comparing and analyzing the performance of the applied algorithms on both the Cleveland and Statlog heart datasets, this research contributes to the advancement of ML techniques in the medical field. The developed ML system offers a valuable tool for healthcare professionals in the early prediction and diagnosis of cardiovascular diseases, with implications for the prediction and diagnosis of other diseases as well.

Incidentally detected noninfectious thoracic aortitis: A clinical approach.

Noninfectious aortitis is occasionally detected incidentally, either on imaging or on histopathologic review after open thoracic aortic surgery. It can present as a clinically asymptomatic, seemingly focal lesion, as diffuse inflammation throughout several aortic segments but sparing the branch vessels, or as a manifestation of a widespread systemic condition. Treatment differs based on etiology, so once identified, all patients with aortitis need a thorough evaluation, laboratory tests, complete large-vessel imaging, and a referral to a vasculitis expert. All patients with aortitis are at high risk of future vascular complications and should be followed with serial clinical evaluations and imaging.

Use of dexmedetomidine during light versus deep anaesthesia on postoperative delirium among elderly patients undergoing major non-cardiac surgery: protocol for a multicentre randomised factorial trial.

Elderly patients are at a high risk of postoperative delirium (POD), leading to increased postoperative morbidity and mortality. The use of dexmedetomidine and depth of anaesthesia may influence POD. This study aims to determine the effects of dexmedetomidine infusion versus normal saline placebo during light versus deep anaesthesia on POD among elderly patients undergoing major non-cardiac surgery. This prospective, multicentre, randomised, controlled, factorial trial will be conducted at three tertiary hospitals in Jiangsu, China. We will recruit a total of 420 patients who are at least 60 years old and undergoing major non-cardiac surgery (thoracic, abdominal, urology, orthopaedic and spine surgery) under general anaesthesia. Patients will be randomised (1:1:1:1) to receive one of four anaesthesia regimens: (1) dexmedetomidine and light anaesthesia, (2) dexmedetomidine and deep anaesthesia, (3) placebo and light anaesthesia or (4) placebo and deep anaesthesia. Dexmedetomidine will be infused at 0.5 µg/kg/h throughout surgery, and intraoperative bispectral index target will be 55 for light anaesthesia and 40 for deep anaesthesia. The primary outcome is the occurrence of POD during the first 7 days postoperatively or until hospital discharge, assessed using the 3-min Confusion Assessment Method two times per day. The secondary outcomes include days with POD, type of POD, pain scores at rest and on movement at 24 and 48 hours postoperatively, patient-controlled intravenous fentanyl consumption during 0-24 and 24-48 hours postoperatively, hypotension, bradycardia, postoperative nausea and vomiting, non-delirium complications, length of postoperative hospital stay, 30-day cognitive function and 30-day mortality. Data will be analysed on a modified intention-to-treat basis. This trial was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University and each participating centre. The trial results will be published in a peer-reviewed journal. Chinese Clinical Trial Registry (ChiCTR2300073271).