Implementation of Standardized ERAS Protocol in Patients Undergoing Minimally Invasive Heart Surgery

Background: ERAS (enhanced recovery after surgery) is an integrative, interdisciplinary perioperative protocol aiming to improve recovery and reduce complications after major surgery. Core elements are appropriate patient selection, minimally invasive approach, immediate extubation after surgery in the operating room, transfer to the recovery unit, intensive physiotherapy under adjusted pain medication, and early discharge from hospital. We aimed to analyze initial results of ERAS in minimally invasive heart surgery (MIHS) which was implemented in university hospital without previous ERAS experience.

Method: ERAS was implemented in January 2021 until September 2021 in a consecutive cohort of 113 MIHS patients. Retrospective cohort analysis was performed providing information about safety and potential benefits of ERAS. Primary endpoints were ERAS-associated complications and hospital length of stay (LOS) in comparison to a historical control cohort.

Results: A total of 113 consecutive patients (mean age 60 ± 9 years, 67% male) underwent MIHS using ERAS at our institution. Surgical access was right anterolateral mini-thoracotomy in 63 (56%) patients who underwent mitral and/or tricuspid valve surgery (n = 60), closure of atrial septal defect (n = 2) or resection of left atrial tumor (n = 1). The remaining 50 (44%) patients had partial upper sternotomy including aortic valve repair/replacement (n = 39) and aortic root/ascending surgery (n = 11). 105 (93%) patients passed through the entire ERAS protocol. 8 patients were crossovers to the standard care due to intraoperative complications (n = 3), hemodynamic instability (n = 3) and respiratory insufficiency (n = 2). ERAS associated complications were early reintubation in two (2%) patients and two (2%) bleeding events requiring re-thoracotomy. No patient had postoperative delirium or wound healing complications. LOS in the ERAS cohort was systematically reduced to 6.8 ± 3.9 days in comparison to historical controls (10.6 ± 5.2 days, p < 0.001). 5 (4%) readmissions were required from the rehabilitation clinic due to atrial fibrillation or pericardial effusion.

Conclusion: Implementation of standardized ERAS protocol in minimally-invasive heart surgery is possible and safe in an institution without previous ERAS experience. Systematic implementation of ERAS approach enables an effective use of limited in-hospital resources and allows faster hospital discharge without compromising patients’ safety. Establishment of interdisciplinary/interprofessional ERAS team with shared decision-making algorithm is the key prerequisite for successful.

Publication History

Article published online:
03 February 2022