Background: The interdisciplinary ERAS (enhanced recovery after surgery) protocol aims to improve patients` outcome after major surgery and comprises as fundamental elements proper patient selection, minimally-invasive surgical access, immediate extubation in the OR, transfer to the recovery unit, intensive physiotherapy under adjusted pain medication starting on the operation day and early discharge from hospital. In this study, we aimed to investigate safety and feasibility of ERAS in patients undergoing minimally-invasive cardiac surgery in an institution without previous ERAS experience.

Methods: From 01/2021 to 09/2021, 113 consecutive patients underwent minimally-invasive cardiac surgery at our institution and were treated according to the ERAS protocol. Retrospective cohort analysis was performed considering ERAS-associated complications and hospital length of stay (LOS) in comparison to a historical cohort to investigate “safety” and protocol adherence was evaluated to investigate “feasibility”.

Results: Mean age was 60±9 years and 67% of the patients were male. Surgical access was partial upper sternotomy in 44% (n=50) for aortic valve repair/replacement (n=39) or aortic root/ascending surgery (n=11) and right anterolateral mini-thoracotomy 56% (n=63) for mitral and/or tricuspid valve surgery (n=60), closure of atrial septal defect (n=2) or resection of left atrial tumor (n=1).

Safety: ERAS-associated complications were early reintubation in 2% (n=2) of patients and in 2% (n=2) bleeding events requiring re-thoracotomy occured. There were no postoperative delirium or wound healing complications. LOS in patinets treated according to the ERAS protocol was significantly reduced to 6.8±3.9 days in comparison to historical controls (10.6±5.2 days, p<0.001). 4% (n=5) readmissions were required due to atrial fibrillation or pericardial effusion.

Feasibility: Complete protocol adherence was achieved in 93% (n=105), in the remaining 8 patients cross-over to standard care was necessary due to medical conditions (intraoperative complications n=3, hemodynamic instability n=3, respiratory insufficiency n=2) but not due to inconsistent ERAS protocol implementation.

Conclusion: In this study, ERAS in patients undergoing minimally-invasive cardiac surgery was proven to be a safe and feasible concept being implemented in an institution without previous ERAS experience. The potential benefits compared to standard perioperative care need to be evaluated further in prospective randomized controlled trials.