Abstract 266 Interprofessional Enhanced Recovery After Surgery (ERAS) after Minimally Invasive Cardiac Surgery - An Update on Clinical Implications in a Real World Setting

Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w

Interprofessional Enhanced Recovery After Surgery (ERAS) after Minimally Invasive Cardiac Surgery - An Update on Clinical Implications in a Real World Setting

S. Stock¹, S. Berger-Veith¹, S. Al Wheibi¹, A. Topal¹, N. Abdelmoteleb¹, T. Owais¹, B. Kloth¹, E. Girdauskas¹

¹Klinik für Herz- und Thoraxchirurgie, Universitätsklinikum Augsburg, Augsburg;

OBJECTIVES: In the era of a constantly increasing repertory of interventional valve therapies allowing for a minimum of trauma and fast recovery, subsequently there is a need to also rethink cardiac surgery in order to keep pace with. ERAS (Enhanced Recovery After Surgery) is an integrative, multidisciplinary care protocol aiming to optimize perioperative management and outcomes. In minimally invasive cardiac surgery (MICS), there is growing evidence that ERAS not only has the potential to fast-track patients´ recovery and improve perioperative outcome but also to save health care cost. Core elements are proper patient selection, minimally invasive surgical access, immediate extubation in the OR, transfer to recovery unit (no intensive care unit stay necessary), early and intensive physiotherapy starting on the operation day and early discharge from hospital. We aimed to analyze perioperative results of ERAS in MICS in a real world setting and to identify potential risk factors for ERAS failure.

METHODS: Between 01/2021 and 03/2022, a consecutive cohort of 223 MICS patients were treated with ERAS at our institution. For this analysis, patients with active endocarditis (n=7) were excluded. Retrospective cohort analysis was performed on the remaining 216 patients. Primary endpoint was ERAS failure, secondary endpoints were ERAS-associated complications and postoperative length of stay (LOS). Rate of ERAS failure was also analyzed in the following subgroups: age >75 years, left ventricular ejection fraction (LVEF) ≤35%, aortic cross clamp time (ACC) ≥90min.

RESULTS: Mean age was 62±13 years (22-83), 61% were male, LVEF was 58±9% (24-78) and EuroScore II was 1.5±1.2% (0.5-9.9). 124 patients were operated via right lateral minithoracotomy and 92 via partial upper sternotomy. Mean extracorporeal circulation time (ECC) was 121.7±32.6 min (54-242) and ACC was 65.5±20 min (0-142). ERAS failure was recognized in 42 (18%). Reasons for ERAS failure were intrahospital death in 17%, surgical complications in 40%, hemodynamic instability in 26% and insufficient respiratory stability for extubation in 24%. Age, BMI, rate of mild COPD, LVEF and ACC were compared in patients with ERAS failure vs. successful ERAS in table 1. There were no ERAS associated complications like early re-intubation due to impaired gas exchange. LOS was 7.6±3. 2 days (4-26). In patients >75 years (n=31), ERAS failure occurred in 8 (25%). Considering patients with LVEF ≤35% (n=11), ERAS failure occurred in 7 (64%). In patients with ACC ≥90min (n=24), ERAS failure occurred in 11 (46%).

Table 1

Eras Failure	Age (years)	BMI (kg/m²)	Mild COPD	LVEF (%)	ACC (min)
Yes (n=42)	66.6±11.16	27.15±5.03	4 (9.5%)	53.9±12.6	77±25
No (n=174)	61.45±13.3	25.74±3.77	7 (4%)	59.4±7.6	62.9±17.9

CONCLUSION: In our MICS patient cohort, ERAS proofed to be a safe and feasible concept for the vast majority of patients. Main reason for ERAS failure was surgical complications. In case of ERAS failure, patients tended to be older, had higher BMI, more often mild COPD, lower LVEF and longer ACC. The rate of ERAS failure remarkably increased with LVEF ≤35% and ACC ≥90min, whereas age >75 years had no relevant impact on ERAS failure.

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