Feasibility of Ultra-Fast-Track Enhanced Recovery After Surgery (ERAS) in Patients with Heart Failure with Reduced Ejection Fraction

Background: Enhanced Recovery After Surgery (ERAS) is an interdisciplinary perioperative approach to improve recovery and reduce morbidity after major surgery. Core Ultra-Fast-Track (UFT-)ERAS goals are extubation in the OR, transfer to a recovery unit instead of the ICU, early physiotherapy, and early discharge from hospital. Patients with Heart Failure with reduced Ejection Fraction (HFrEF) present a challenge in recovery from cardiac surgery due to the risk of low-cardiac output syndrome as well as postoperative decompensation.

Methods: 505 consecutive patients underwent minimally invasive valve or aortic surgery and perioperative UFT-ERAS at our institution between 01/2021 and 09/2023. Of these, 33 had an LVEF of ≤40% and 4 an LVEF of ≤30%. Outcomes of interest were Major Adverse Cardiac Events (MACE), bleeding requiring reoperation, UFT-ERAS-associated complications (reintubation, readmission to the ICU), and ERAS achievement in five items: (1) extubation in the OR, (2) transfer to intermediate care instead of ICU, (3) immediate physiotherapy, (4) transfer to the floor within 24 h, and (5) discharge from hospital within 7 days. Successful UFT-ERAS was defined as ≥3 items, partial as 1 to 2 items, and failure as 0 items.

Results: Patients’ median age was 67 years (IQR 58–72), 40% were female, and median LVEF was 35% (IQR 35–40). 24 (65%) patients received anterolateral minithoracotomy for mitral valve surgery, mostly for functional mitral regurgitation. The remaining 13 (35%) patients had partial upper sternotomy for aortic valve repair/replacement (n = 11) or aortic root surgery (n = 2), mostly for aortic regurgitation. There were no mortalities or MACE events, and 3 (8%) instances of bleeding requiring reoperation. In terms of possibly ERAS-related complications, there was one reintubation and no readmissions to ICU. Median time to extubation was 16 minutes (IQR 10–177). In 26 (70%) patients UFT-ERAS was successful, in 6 (16%) patients it was partial, and 5 (14%) patients were treated with standard of care. Failure to achieve UFT-ERAS was primarily due to hemodynamic compromise, resulting in delayed extubation and extended catecholamine therapy. Median postoperative length of stay was 7.5 days (IQR 6–10).

Conclusion: Our data show moderate success of an UFT-ERAS program in HFrEF patients. However, prolonged hemodynamic compromise regularly impedes postoperative recovery. Pharmacologic preconditioning might therefore be a helpful adjunct to improve UFT-ERAS for this cohort.

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Artikel online veröffentlicht:
11. Februar 2025