Fast-Track Extubation in Infants <7 kg Undergoing Congenital Heart Surgery is a Safe, Feasible, and Cost-Effective Concept: A 5-Year Single-Center Experience

Objectives: Infants undergoing surgical repair of congenital heart defects using cardiopulmonary bypass (CPB) are known to be highly susceptible to the effects of postoperative mechanical ventilation (MV). We have implemented the fast-track (FT) concept of early extubation (<8 hours postoperatively) to reduce additional mortality and morbidity related to prolonged MV. The outcome of infants weighting <7 kg was compared. Furthermore, we sought to determine risk factors for prolonged MV.

Methods: A retrospective review of all infants <7 kg undergoing congenital heart surgery on CPB from January 2014 to January 2019 was performed. FT versus non-FT patients (>8 hours of extubation) were compared in terms of baseline characteristics, intraoperative parameters, and postoperative outcome using Chi-square test. Propensity score matching using the method of the nearest neighbor (caliper = 0.2) was performed for fair comparison between the two groups. p-Values of &≤0.05 were considered statistically significant.

Result: A total of 716 infants: FT group (n = 182, 25.5%) versus non-FT group (n = 534, 74.5%) were reviewed. Median age in the entire cohort was 4 months (range: 0–34.6), STS-EACTS (STAT) mortality score ranged between 0.1 and 4. The annual rate of FT patients increased significantly during the studied period (2014 vs. 2018: 3.8 vs. 43%, p < 0.01). A younger age, a lower body weight, the presence of a genetic disorder, a higher STAT score, as well as longer operating times (CPB and crossclamping times), were associated with prolonged MV and were therefore significantly higher in the non-FT group. FT was applied in procedures up to STAT score of 2. After propensity matching (123 pairs), the two groups did not differ significantly in these parameters. The FT group, however, showed tendency toward a lower early mortality: 0 versus. 2.8% (p = 0.08), a significantly shorter ICU length of stay (in hours): 42.1 (22–68.3) versus. 124.9 (71–211; p < 0.01), significantly lower postoperative transfusion rates: 61.3 versus 77% (p < 0.01), and significantly lower vasoactive-inotropic scores (VIS): 1.9 (0–6.6) versus 4.8 (0–12.7; p = 0.02). Reintubation rate did not differ significantly between the groups (p = 0.7).

Conclusion: FT extubation proved to be safe and feasible in infants <7 kg undergoing reconstructive cardiac surgeries with lower transfusion rates, vasoactive scores, and ICU stays suggesting a more effective resource management. We therefore recommend FT in congenital heart surgery up to STAT score of 2.