Clinical Evaluation of on-Table Extubation in Patients Aged Over 60 Years Undergoing Minimally Invasive Mitral or Aortic Valve Replacement Surgery

Routine Extubation in the Operating Room After Minimally Invasive Aortic Valve Replacement

Objective: The present study aimed to evaluate the feasibility and safety of performing extubation in the operating room following aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT), as the safety profile of this approach has not been fully established. Methods: We conducted a retrospective analysis of patients who underwent isolated AVR through a RAMT between February 2012 and December 2023. Emergency cases and reoperations were excluded. Patients were categorized according to the location of extubation-either in the operating room (on-table) or in the intensive care unit (ICU). Multivariable logistic regression analysis was used to identify predictors associated with successful on-table extubation. Results: Among 423 patients who underwent non-emergent isolated AVR, 73.3% were extubated in the operating room. This group was characterized by younger age, lower EuroSCORE II, and higher preoperative serum albumin levels. While the surgical techniques did not differ between groups, those extubated on-table had significantly shorter cardiopulmonary bypass times (84.0 [68.0-104.0] vs. 104.0 [85.0-131.5], p < 0.001). Although early postoperative outcomes were comparable, the on-table extubation group had significantly shorter ICU stays (24.0 [22.0-26.0] vs. 25.0 [23.0-30.0], p < 0.001) and hospital stays (5.0 [4.0-6.0] vs. 6.0 [5.0-8.0], p < 0.001). A predictive model incorporating age, albumin levels, and cardiopulmonary bypass time demonstrated a predictive accuracy of approximately 78.4% for on-table extubation success. Conclusions: Extubation in the operating room was found to be both safe and effective for the majority of patients undergoing isolated AVR via RAMT. It was associated with low reintubation rates and significantly reduced lengths of ICU and hospital stays. These findings support the adoption of routine on-table extubation in suitable patients undergoing this procedure.

The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies

Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.

On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery

OBJECTIVES

Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery.

METHODS

Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home.

RESULTS

Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7.

CONCLUSIONS

Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.