Objective: To evaluate the cumulative incidence and predictors of postoperative visual and auditory hallucinations among hyperlipidemic and
normolipidemic patients undergoing cardiac surgery, with a particular focus on lipid indices, especially the low-density lipoprotein/high-density
lipoprotein (LDL/HDL) ratio.
Design: Multicenter, prospective cohort study with daily postoperative assessments from days 1-4 and follow-up to day 7, using Kaplan-Meier
estimation and multivariable Cox proportional hazards regression.
Setting: Ten tertiary cardiac surgery centers across the West Bank of Palestine.
Participants: Adults (18 years) undergoing coronary artery bypass grafting or valve surgery (N = 1,332), stratified as hyperlipidemic (n = 448)
or normolipidemic (n = 884) according to preoperative lipid profiles. Patients with incomplete records, cognitive impairment, language barriers,
or psychiatric illness were excluded.
Interventions: None (observational study).
Measurements and Main Results: Postoperative hallucinations were assessed using the validated Questionnaire for Psychotic Experiences. By
day 7, visual hallucinations occurred in 11.2% of hyperlipidemic and 10.3% of normolipidemic patients, while auditory hallucinations occurred
in 7.1% and 6.3%, respectively. The LDL/HDL ratio independently predicted both visual and auditory hallucinations in hyperlipidemic (visual:
adjusted hazard ratio [aHR] 1.136, p = 0.016; auditory: aHR 1.146, p = 0.017) and normolipidemic (visual: aHR 1.123, p = 0.038; auditory: aHR
1.110, p = 0.047) cohorts. Longer aortic cross-clamp time increased visual hallucination risk (aHR 1.007; p = 0.015), while intraoperative fenta-
nyl exposure reduced both visual (aHR 0.435; p = 0.011) and auditory (aHR 0.377; p = 0.023) hallucinations. A critical preoperative state pre-
dicted auditory hallucinations in hyperlipidemic patients (aHR 3.904; p = 0.001).
Conclusions: Elevated LDL/HDL ratio is a significant predictor of postoperative hallucinations. Integrating lipid profile evaluation into periop-
erative risk assessment may enhance neuropsychiatric outcomes following cardiac surgery.
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Keywords: hyperlipidemia; cardiac surgery; hallucinations; LDL/HDL ratio; neuropsychiatric complications; VAACS Study

Title

Journal of Cardiothoracic and Vascular Anesthesia

Publisher

Elsevier

Publisher Country

United States of America

Indexing

Scopus

Impact Factor

None

Publication Type

Online only

Volume

40

Year

2026

Pages

1155 -1170