Enhanced recovery after minimally invasive valve surgery - ultra-fast extubation versus standard weaning strategy

Immediate extubation in the operating room (OR) following cardiac surgery remains controversial. In 2021, our institution implemented a fast-track protocol that incorporated ultra-fast extubation (ORE) for minimally invasive heart valve surgery. We retrospectively evaluated outcomes and cost-effectiveness in comparison to standard extubation in the ICU (ICE). We retrospectively reviewed 615 minimally invasive valve surgeries performed between 2019 and 2023. Among these, 228 patients were extubated in the ICU, if possible, within 6 h as per current guidelines, while 387 patients underwent immediate ultra-fast extubation in the operating room (ORE) at the end of the surgery. Baseline variables were compared, and case-control matching was performed based on significantly different factors: Age, BMI and cross clamp times, resulting in two matched groups of 122 each. After matching, baseline variables were comparable between groups. Patients who underwent ORE had shorter ICU and hospital stays, were less likely to require ventilation for more than 24 h, and had significantly less often respiratory failure. Rates of repeat intubation did not differ significantly between groups. In multivariate logistic regression analysis, ORE, aortic cross clamp time, and EuroSCORE II were independent predictors of prolonged ventilation (> 24 h). However, conversion to sternotomy, previous cardiac surgery, gender, and history of smoking were not significantly associated with prolonged ventilation. ORE also led to reduced costs (Standard mean difference: 10 247€, p = 0.03). Ultra-fast extubation after minimally invasive valve surgery was associated with improved respiratory outcomes and lower costs compared to standard extubation in the ICU, with no increase in re-intubation rates. These findings support the clinical feasibility and safety of OR extubation in selected patients at experienced centers.