Fast-track extubation in minimally invasive cardiac surgery: limits and lessons of a 4-year single-center analysis

Fast-track extubation is a key component of the interdisciplinary treatment concept Enhanced Recovery After Surgery (ERAS). In preparation for implementing ERAS as a comprehensive approach, we aimed to analyze the current state of fast-track extubation in the operating room, focusing on Minimally Invasive Cardiac Surgery (MICS). Specifically, we assessed the potential benefits of immediate on-table extubation compared to extubation within six hours after the completion of MICS.

During a 4-year period from 2019-2023, a total of n = 146 patients underwent MICS at our institution. Surgical aspects were retrospectively analysed along with patients' risk profiles and relevant comorbidities. After 1:1 best neighbor propensity score matching, patients who were admitted to intensive care unit intubated but were extubated within six hours after surgery (fast-track, FT) were compared to those who were extubated in the operating room (extubation in tabula, EIT). The primary endpoint was fast-track failure (FTF), a composite of setbacks in the postoperative course: revision surgery, re-intubation, and readmission to ICU or intermediate care unit (IMC).

Patients had a median age of 61 years (IQR: 51.3-67.8) and were predominantly male (76.7%). The primary study endpoint occurred in 20.0% of all matched patients (FT: 26.7%, EIT: 13.3%; p = 0.289). FT patients had longer cardiopulmonary bypass times [FT 165.0 min (146.5-217.5); EIT 158.5 min (128.0-189.5); p = 0.047], but the duration of surgery was comparable. Additionally, the average length of hospital stay did not differ. A multivariate analysis was conducted and identified preoperative atrial fibrillation and intraoperative hypothermia as predictive risk factors for FTF.

According to our retrospective single-center analysis, extubation in the operating room is feasible and safe even outside of a structured ERAS program. However, as itself it does not impact the further hospital stay, if there is no action thereafter, e.g., same day physiotherapy.