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Article Open Access

Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings

  • Authors:
    • Hu Cheng
    • Yali Yasen
    • Xiao Cheng
    • Zhenfei Hu
    • Xueyan Li
    • Jianjiang Wu
    • Wenbing Yu
    • Jiang Wang
  • View Affiliations / Copyright

    Affiliations: Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang 830000, P.R. China
    Copyright: © Cheng et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 89
    |
    Published online on: May 26, 2026
       https://doi.org/10.3892/br.2026.2162
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Abstract

Postoperative cognitive dysfunction (POCD) is a frequent complication of cardiac surgery. The present study aimed to quantify changes in Mini‑Mental State Examination (MMSE) scores following on‑pump cardiac surgery and explore potential study‑level moderators associated with variability in cognitive outcomes. A systematic review and random‑effects meta‑analysis was performed following PRISMA guidelines. MEDLINE, Embase, Cumulative Index to Nursing & Allied Health Literature, Cochrane, PsycINFO, Web of Science, and Scopus were searched up to May 2025; eight prospective single‑center cohorts (867 patients) met predefined criteria, providing 14 independent pre/postoperative comparisons of cognitive function. The mean MMSE score was extracted at baseline and final reported follow‑up (7 days to 6 months). Hedges' g was pooled using a random‑effects model; heterogeneity was summarized with τ² and I², and a 95% prediction interval (PI) was calculated. Overall, cardiac surgery was associated with a moderate decline in MMSE scores (g=‑0.60, 95% confidence interval, ‑0.85 to ‑0.35; P<0.001). Heterogeneity was high (τ²=0.178; I²=88.8%), yet leave‑one‑out and Hartung‑Knapp adjustments produced similar estimates. The 95% PI (‑1.56 to 0.36) spans both negative and slightly positive values, indicating that while most cohorts show cognitive decline, the inclusion of values above zero suggests that small improvements remain possible in some populations. Subgroup analysis showed a large decline among patients meeting POCD criteria (g=‑0.893) compared with a small, non‑significant change in non‑POCD patients (g=‑0.274; Q_between=9.08, P=0.003). Meta‑regression identified cardiopulmonary‑bypass time as the only statistically significant moderator (β=‑0.014 MMSE SD units/min; P=0.023), explaining ~50% of between‑study variance. Funnel‑plot tests suggested possible small‑study effects, but trim‑and‑fill imputed no missing studies and Rosenthal's fail‑safe N was 431, supporting the robustness of the pooled estimate. These findings suggest that on‑pump cardiac surgery is frequently associated with a moderate decline in global cognitive performance as measured by the MMSE, particularly among patients who develop clinical POCD. Awareness of this association may support perioperative cognitive monitoring and efforts to minimize modifiable intraoperative factors such as prolonged cardiopulmonary bypass duration.
View Figures

Figure 1

PRISMA flow diagram of study
selection. Of 1,564 records identified and 24 additional references
from manual search, 312 duplicates were removed, leaving 1,252
titles/abstracts for screening. Following exclusion of 1,160
ineligible citations, 72 full-text articles were assessed; 64 were
excluded for predefined reasons (no Mini-Mental State Examination
data, n=21; review/editorial/abstract, n=13; ineligible study
design, n=12; mixed cohorts without extractable cardiac subgroup,
n=10; overlapping populations, n=8). In total, eight studies met
all criteria and yielded 14 independent pre/post comparisons
included in qualitative and quantitative synthesis.

Figure 2

Forest plot of pre- vs. postoperative
Mini-Mental State Examination change in cardiac surgery patients.
Each horizontal line shows the study-specific Hedges g and 95% CI;
squares are centered on point estimates and scaled to study weight.
The diamond represents the pooled random-effects estimate (g=-0.60,
95% CI -0.85 to -0.35). Substantial between-study heterogeneity is
reflected by τ²=0.178 (I²=88.8%). A 95% prediction interval (-1.56
to 0.36) beneath the pooled diamond indicated the range in which
the true effect of a future comparable study is likely to lie. Std
diff, standard difference; NPOCD, no postoperative cognitive
dysfunction.

Figure 3

Subgroup forest plot comparing
patients with and without POCD. Separate pooled estimates are shown
for POCD (eight comparisons) and NPOCD (six comparisons). Patients
with POCD exhibited a large decline (g=-0.893, 95% CI -1.258 to
-0.527), whereas patients with NPOCD show a small, non-significant
change (g=-0.274, 95 % CI -0.631 to 0.084). The test for subgroup
difference yielded Q_between=9.08 (P=0.003). Std diff, standard
difference; NPOCD, no postoperative cognitive dysfunction.

Figure 4

Leave-one-out sensitivity plot for
the pooled Mini-Mental State Examination effect. Each point
represents the overall Hedges'g recalculated after omitting one
comparison at a time; the vertical dashed line marks the
complete-data estimate (g=-0.60). Horizontal error bars show 95%
CIs for each re-pooled estimate. All values remain negative and
significant (range, -0.68 to -0.52; P≤0.002), indicating no single
study unduly contributed to the overall result. Std diff, standard
difference; NPOCD, no postoperative cognitive dysfunction.

Figure 5

Prediction-interval plot of
Mini-Mental State Examination effect sizes. Standard errors are
plotted against Hedges' g on a reversed standard-error scale.

Figure 6

Funnel plot with Egger's regression
line assessing publication bias. Scatter of study effect sizes vs.
standard errors reveals a slight asymmetry, with a relative lack of
large, null-effect studies on the right. The solid regression line
depicts Egger's test (intercept=-3.69, P=0.024). Std diff, standard
difference.

Figure 7

Meta-regression of CPB time vs.
change in MMSE. Bubble area is proportional to the inverse of its
within-study variance (larger bubbles indicate greater weight). The
thick line is the fitted regression (β=-0.014 SMD/min CPB; Z=-2.27;
P=0.023), with the green band marking its 95% confidence limits.
The model explains 50% of the between-study heterogeneity
(R²_analog=0.50), decreasing τ² from 0.198 to 0.100. The plot shows
a clear negative slope: Comparisons with longer bypass runs cluster
toward larger cognitive declines, while those with shorter CPB
times tend toward smaller or negligible MMSE changes, supporting
CPB duration as an independent moderator of postoperative cognitive
outcome. CPB, cardiopulmonary bypass; MMSE, Mini-Mental State
Examination; std diff, standard difference.
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Spandidos Publications style
Cheng H, Yasen Y, Cheng X, Hu Z, Li X, Wu J, Yu W and Wang J: Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings. Biomed Rep 25: 89, 2026.
APA
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J. ... Wang, J. (2026). Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings. Biomedical Reports, 25, 89. https://doi.org/10.3892/br.2026.2162
MLA
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J., Yu, W., Wang, J."Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings". Biomedical Reports 25.1 (2026): 89.
Chicago
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J., Yu, W., Wang, J."Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings". Biomedical Reports 25, no. 1 (2026): 89. https://doi.org/10.3892/br.2026.2162
Copy and paste a formatted citation
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Spandidos Publications style
Cheng H, Yasen Y, Cheng X, Hu Z, Li X, Wu J, Yu W and Wang J: Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings. Biomed Rep 25: 89, 2026.
APA
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J. ... Wang, J. (2026). Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings. Biomedical Reports, 25, 89. https://doi.org/10.3892/br.2026.2162
MLA
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J., Yu, W., Wang, J."Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings". Biomedical Reports 25.1 (2026): 89.
Chicago
Cheng, H., Yasen, Y., Cheng, X., Hu, Z., Li, X., Wu, J., Yu, W., Wang, J."Cognitive dysfunction after cardiac surgery: A systematic review and meta‑analysis on the mini‑mental state examination findings". Biomedical Reports 25, no. 1 (2026): 89. https://doi.org/10.3892/br.2026.2162
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