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

Introduction: Immediate extubation in the operating room (OR) following cardiac surgery remains debated. In 2021, our institution implemented a fast-track protocol including ultra-fast extubation (ORE) for minimally invasive heart valve surgery. We retrospectively evaluated outcomes and cost-effectiveness compared to standard extubation in the ICU (ICE). Methods: We retrospectively reviewed 615 minimally invasive valve surgeries performed between 2019 and 2023. Among these, 228 patients were extubated within 6h of intensive care unit arrival (ICE), 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. Result : 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 24hours, and had significantly lower 30-day mortality. 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 (>24hours). However, conversion to sternotomy, previous cardiac surgery, gender, and history of smoking were not significantly associated with prolonged ventilation. The relative risk of prolonged ventilation was significantly reduced with ORE (number needed to treat (NNT) of 5.3 patients (95% CI: 3.9–8.6, p=0.006) to prevent ventilation >24hours ORE also led to reduced costs in the matched cohorts (Standard mean difference: 10 247€, p=0.03). Conclusion: Ultra-fast extubation after minimally invasive valve surgery was associated with improved short-term outcomes and lower costs compared to standard extubation in the ICU, with no increase in re-intubation rates. These findings support the feasibility of OR extubation in selected patients at experienced centers.