Fast track as a routine for open-heart surgery

Fast track surgery, Off-pump coronary artery surgery, Normothermia

We congratulate Oxelbark et al. [1] for their excellent results with fast-track open-heart surgery, but one fundamental question arises. Is fast-track anesthesia combining thoracic epidural anesthesia (TEA) and general anesthesia [2,3] indeed the ‘top end’ in the state of the art?

Using ultra-short acting opiates general anesthesia without TEA, we operated on 62 patients from January 2001 through July 2001. All these patients were unselected, their mean age was 62 (46–78) years, M/F ratio 3.7. Left ventricular ejection fraction was ≪30% in one patient (1.7%), 30–55% in 14 (23.7%), and over 55% in 44 patients (74.6%). The method was used for 61 coronary artery bypass grafting (CABG) procedures — of this number 48 were off-pump CABG — and for aortic valve replacement in one case. In all on-pump procedures, normothermic cardiopulmonary bypass and cold crystalloid cardioplegic solution were used. Hypothermia prevention was essential in all patients.

General anesthesia was started by continuous infusion of remifentanil (Ultiva Glaxo Wellcome, UK), followed by single shots of propofol (Diprivan AstraZeneca, UK), and atracurium (Tracrium Glaxo Wellcome, UK) for muscle paralysis. Anesthesia was then maintained by further continuous remifentanil and by inhaled isoflurane (Forane Abbott, UK) with an oxygen and air mixture at a 1:1 ratio. Continuous atracurium was again administered for muscle relaxation. After reaching standard extubation criteria, 59 patients were extubated while still in the operating room (within 10 min after the end of the procedure). Because of the absence of an epidural catheter, satisfactory postoperative pain control posed a problem, with very-low-dose continuous remifentanil being apparently the best solution.

The hemodynamic stability of patients with anesthesia as described above did not vary from those under standard general anesthesia used routinely in our department. Seven patients (11.9%) required small doses of cathecholamines intraoperatively and in the very early postoperative period.

Three patients (4.8%) were converted to conventional general anesthesia because of intraoperative hemodynamic instability, the postoperative course of these patients was uncomplicated, although one of them developed laboratory signs of myocardial infarction. Transient and mild neurological complications were observed in three patients (4.8%). No patient was reintubated due to respiratory or cardiac failure. No patient died within 30 days postoperatively, the mean length of hospital stay was 6.7 days (3–12).

The term ‘minimally invasive’ in cardiac surgery could refer not only to less invasive surgical strategies but, also, to the use of less invasive anesthetic techniques. We expect the term ‘minimally invasive cardiac anesthesia’ as the mirror image of the term ‘minimally invasive cardiac surgery’ be coined in the immediate future, with fast-track anesthesia without TEA being the first step.