Fast track cardiac surgery started in the late 1980s due to a rapid growing amount of operations putting a high pressure on resources, particularly on intensive care capacity. The early fast track studies showed that this technique is feasible and safe for selected patients and procedures. Although some limitations of fast tracking such as patient age, co-morbidities and prolonged operation time were later described, this did not stop further extension of patient and procedure selection criteria. Nowadays, fast track pathways are used to improve patient care as a shorter ICU stay seems to decrease mortality. These pathways are applicable to various surgeries, including aortic valve procedures and combined surgery, because of the development of surgical and bypass techniques which allow less invasive anaesthesia or even conscious sedation. In principle, every patient could be treated as a fast track patient if preparation of the patient and scheduling of the operations are considered. Several strategies could optimise the physiological condition of patients and broaden the patient selection criteria. Avoidance of perioperative anaemia might be as important as keeping the haemodynamic condition stable to achieve optimal organ protection. Current selection criteria should be based on surgical parameters and augmented with the patient s frailty and performance status. All of them should be continuously adjusted during the process. However, most important is a concerted team approach with all contributors having the same mindset.

Introduction

Since its advent, cardiac surgery has traditionally been based on high doses of opioid anaesthesia to ensure stabile haemodynamic conditions. In addition, a patient’s body temperature was actively lowered to provide organ protection. However, this strategy necessitated prolonged post-operative mechanical ventilation which was frequently extended until the morning after the operation.

Fast track cardiac surgery developed in the late 1980s and early 1990s, because of the increasing number of coronary artery bypass graft (CABG) procedures putting a high pressure on resources, particularly on intensive care unit (ICU) capacity.1,2 The main principles of this ‘new’ technique were achievement of extubation within 1–10 h of the operation and early ICU discharge, followed by transfer to medium care and the general ward. There were three aims during anaesthesia: lower doses of opioids and hypnotics, keeping patients normothermic and facilitating early extubation.3 After the introduction of short-acting opioids and hypnotics, the algorithms for fast track cardiac surgery were quickly implemented in clinical practice, because this concept proved to be safe and cost-effective. This led to a widening of the inclusion criteria for fast track anaesthesia from so-called low risk patients less than 70 years old scheduled for CABG surgery, with few co-morbidities and good cardiac function, to older patients with more co-morbidities. In parallel, the range of suitable procedures was extended to include aortic and mitral valve procedures, and combinations of single valve operations plus CABG.

Over time several authors have suggested that every patient could be treated as a ‘fast track’ patient until proven otherwise.4 However, there were some drawbacks leading to occasional failure of the protocol. In the literature there is a wide range of failure rates: between 11% and 63% of patients scheduled for a ‘fast track’ protocol.5,6 One reason for this broad range may be the various definitions of fast track anaesthesia.7 On the other hand, it seems that in older literature the failure rate is higher than in more recent reports. The progression of surgical techniques (minimally invasive and percutaneous techniques), extracorporeal support (smaller systems) and the change to normothermic bypass conditions may have been the main drivers of this improved success.8–10

Currently, there is a switch in mindset from saving ICU resources to improvement of patient care. This means rapid progression through the surgical process with a short stay on the ICU—or even avoidance of the ICU—which could be advantageous for patients.11 Of course, minimally invasive surgery has been a cornerstone of this development, because the much lower tissue trauma results in earlier recovery.

Patients for cardiac surgery including valve procedures are currently older and have more co-morbidities than at the beginning of the fast track programmes. In contrast, the general results regarding morbidity and mortality have improved. In valve surgery, the evolution of better devices and reduction of peri-operative trauma have contributed to this success.12 The development of minimally invasive surgical techniques was introduced in cardiac surgery in the late 1990s by Navia, Cosgrove, and Cohn, who performed the first minimally invasive valve procedures. They were followed by others who performed cardiac surgery with smaller incisions, thoracoscopically and with the use of robots. In parallel, less invasive cardiopulmonary bypass methods were implemented which resulted in minimal immunological reactions and reduced blood loss.8,13

The new surgical techniques were accompanied by the evolution of advanced devices (e.g. automated knot systems) and modern valve prostheses (e.g. sutureless aortic valves).9,13 At present, valve procedures can be performed percutaneously in a number of indications (e.g. transcatheter aortic valve implantation-TAVI, mitral clip) which contribute to even more reduction in post-operative pain and respiratory impairment. The new methods allow the inclusion of high risk patients who cannot be treated by the traditional surgical approach. Over the last decade there has been a clear trend to less invasive procedures being performed in sicker patients.12 In percutaneous approaches, fast track anaesthesia has been shown to be safe as well as effective.14–16

The purpose of this article is to provide a review of risk factors, patient selection criteria and the possibilities for optimisation of fast track cardiac surgery, with particular attention to modern minimally invasive aortic valve surgery.

Risk factors for prolonged intensive care usage in cardiac surgery

Intensive care unit stay can be a bottleneck in the care pathway and a predictor for failure of fast tracking in general cardiac surgery. Therefore knowledge of patient risk factors could lead to pre-operative improvement of the patient’s condition or to a change of treatment plan. About 72–88% of all unselected patients are discharged from ICU within 1–3 days. Although the EuroScore and Parsonnet score has been shown to predict not only mortality and morbidity but also length of stay on the ICU, several other publications suggested other specific risk factors.17–19 Canver et al. demonstrated in 1998 that independent of age, chronic lung disease (CLD) prolonged ICU stay and lowered 5-year survival after CABG surgery. Rady and co-workers introduced a set of predictors for prolonged ventilation and ICU stay derived from a large database. The authors followed 11 330 unselected cardiac or thoracic aortic surgery patients after ICU admission. They applied a weaning algorithm to all patients within a time frame of 6 h or less if the patients were haemodynamically and respiratory stable, normothermic and without significant blood loss. Only 6.6% of the patients could not be extubated within 6.5 days.20

In 2007, Ranucci et al.21 compared a standard strategy with a goal-orientated strategy in a study of 9120 patients. After changing from a standard to a goal-oriented strategy, the patients were weaned from the respirator and extubated quickly if their haemodynamics were stable and there were no signs of respiratory or neurological complications. Two hours after extubation they could be discharged from the ICU. The authors found age, renal dysfunction, unstable angina, heart failure, re-do or combined surgery, and prolonged cardiopulmonary bypass (CPB) were risk factors for late ICU discharge. Two years later, Cislaghi et al.22 confirmed these results in a cohort of 5123 unselected mixed cardiac surgical patients. They suggested further risk factors such as transfusion of more than four units of red blood cells (RBC) or plasma as contributors to prolonged ICU stay. Similarly, in another study, De Cocker et al.23 increased the list of predictors with some more specific factors (e.g. sex, arrhythmias, mitral insufficiency, and aortic surgery). Recently, LaPar, and co-workers reported peri-operative risk factors for prolonged intensive care stay in a cohort of 13 105 cardiac surgical patients. They completed the list of predictors for extended ICU-stay with more specific aspects of cardiac dysfunction—with or without mechanical or pharmacological support—and also with immunosuppression, infection and technical surgical reasons (duration of cardiopulmonary bypass and type of operation e.g. re-do surgery).24

Risk factors and predictors for failure of fast track approach

By 1995 Mounsey and co-workers had shown the importance of clinical signs, cardiac performance and intra-operative technical details, in a cohort of 431 unselected elective CABG patients. The authors identified renal dysfunction, cardiac impairment and multi-vessel disease, re-do surgery, bypass time and urgency of the operation as risk factors for failure of a fast track protocol. Moreover, they described three groups of risk: low risk patients had a success rate for early ICU discharge of 93% while the medium risk patients reached 83% and the poor risk group 62%. This study determined the first selection criteria for fast track cardiac surgery.25 Four years later, in a cohort of 885 patients scheduled for fast track CABG procedures, Wong et al.26 reported 25% delayed extubation (defined as intubation longer than 10 h) with 17% of the patients staying longer than 48 h on the ICU. In addition to sex and age, the authors showed post-operative bleeding, haemodynamic support and arrhythmias were risk factors for delayed extubation. Myocardial infarction and renal dysfunction had a negative influence on ICU-stay. Moreover, the authors presented a cardiac risk score specifically to predict outcome in fast track cardiac surgery.

In 2009, Svircevic et al.27 demonstrated that a fast track pathway is feasible, in a large retrospective study on an unselected group of patients receiving cardiac surgery. Mortality did not differ between the conventional and fast track groups. Interestingly, in both groups mortality was even lower than predicted by EuroScore. At the moment, selection criteria are extended to CABG (on and off-pump procedures), aortic valve replacements with or without combination of CABG and non-complex cardiac surgery (e.g. removal of an atrial myxoma, atrial septal defect closure). But patient performance status still plays a major role. Low physical status, COPD (>Gold 2), cardiac dysfunction and renal impairment are exclusion criteria. The same holds true for emergency operations, re-do surgery and CPB-time of more than 150 min.28 However, in parallel with improvements in surgical and CPB technique, the criteria were challenged again. The results in septuagenerians and octogenerians have encouraged performance of fast track procedures even in this population.6 On the other hand, a study from Parlow et al.29 in obese patients showed that while a fast track pathway is feasible, it carries a slightly higher risk of failure than in non-obese patients. Extubation within 6 h was achieved in 85% of the obese patients compared with 98% in the non-obese.

More recently, several prediction models have been validated. The first of these was presented by Constantinidis et al.30 in 2006 and confirmed by Lee and co-workers in 2013.31 The strongest predictor is renal impairment after re-do surgery and poor left ventricle (LV) function. Kiesling et al.’s32 group reduced the number of predictors to three: ASA above three, NYHA class above three and operation time longer than 267 min. Whereas Haanschoten et al.28 showed age and poor LV function (< 35%) to be the best predictors.

Factors affecting minimally invasive valve surgery

In a study population of 2511 non-selected CABG patients, an incidence of 6.2% for post-operative renal dysfunction was found to be associated with the worse outcome. In a multivariate analysis to determine predictors, the authors listed age, angina pectoris symptoms, diabetes mellitus, cardiopulmonary bypass time and pre-existing renal impairment as risk factors. Renal dysfunction was associated with increased in-hospital mortality, prolonged mechanical ventilation and ICU stay. Moreover these patients developed more infections (pulmonary, sepsis and deep wound infections) and needed more haemodynamic support.33

As increasing age is associated with lower performance status, it could also serve as a predictor for post-operative outcomes in valve surgery. However, several studies showed acceptable results for this population (older than 80 years) in aortic valve surgery and identified other predictors for peri-operative mortality.34–37 Risk factors comparable to prolonged ICU stay and failure of a general fast track programme have been identified. Renal dysfunction, chronic lung disease, impaired cardiac performance (with or without haemodynamic support), female sex, duration of the procedure and typical cardiovascular risk factors such as diabetes mellitus and arterial hypertension are associated with increased morbidity and mortality.37–39 Moreover, pulmonary hypertension, neurological damage and liver dysfunction are also clinical parameters associated with a worse outcome.37,39

Nguyen et al.40 reported in a study of 1336 traditional surgical aortic valve replacement (SAVR) patients and 321 transcatheter valve replacements that renal dysfunction was a risk factor for increased mortality in the SAVR group only, although in the whole cohort traditional risk factors for aortic surgery (age, ejection fraction (EF), sex) were increased. Although contrast fluids are a risk factor for acute kidney disease, the authors showed that it was the use of contrast fluids rather than the amount used, which increased the risk assessed by the calculated glomerular filtration rate.

In a cohort of 995 patients receiving a TAVI procedure, acute renal impairment occurred in 21%. The incidence of renal problems was associated with peri-operative vascular complications leading to major bleeding. Of note, the amount of peri-operative blood products transfused was a stronger risk factor than the amount of peri-operative contrast fluid used.41 A very recent review on patient selection for TAVI identified chronic lung disease, kidney dysfunction, cardiac performance (including pulmonary hypertension) and frailty (as a composite of age and reduced general performance status) as the most important factors affecting peri-operative outcome in TAVI-procedures.39 The latter study appeared in a recent systematic review from Sepehri et al.42 where the authors analysed six studies with a total of 4765 patients undergoing cardiac surgery including TAVI. They showed that pre-operative performance has a strong relationship with post-operative outcome.

Likewise, a very recent study from O’Neill and co-workers in 392 vascular surgical patients showed the ‘first impression’ assessment of frailty to be predictive for mortality.43

Regarding other percutaneous interventions (e.g. mitral-clip procedures), Ledwoch et al.44 presented a small study of 42 patients undergoing mitral clip interventions. Again renal dysfunction proved to be a risk factor for longer hospitalization.

Patient optimizing strategies

While several risk factors are not modifiable (e.g. age, sex), improvement strategies should focus on the modifiable variables.

In this respect, protecting renal function might be the most important challenge in the peri-operative setting, because it is associated with worse outcomes in all kinds of surgical techniques (SAVR, mini-AVR, TAVI) while the choice of surgical technique seems unimportant.45 In recent literature, mini-AVR, and TAVI-procedures appear to preserve renal function better than SAVR procedures. While this is not unexpected, it is remarkable that mini-AVRs are associated with renal dysfunction to a lesser degree than TAVIs. This might be due to the use of contrast fluids which are associated with impaired renal function. However, the amount of contrast fluids does not necessarily correlate with the degree of renal damage.40,46 Yet, keeping the heamodynamics stable might be the best strategy to prevent renal impairment. Secondly, the choice of fluids might be relevant as balanced solutions are associated with the lowest risk of renal dysfunction and colloids with the highest. Finally, no specific drug has been proven to be renally protective.47 Although a recent meta-analysis carefully points out that levosimendan is associated with reno-protective effects, the authors conclude that the trials were not of high quality and conclusive data are still required.48 The reports for the vasodilator, fenoldapam, are also not clear. The same applies to dexmetomidine, which was also thought to protect renal function.49 Billings et al.50 refuted claims of a potentially beneficial effect of statins on renal function in a study of about 600 patients. Peri-operative anaemia is another contributor to the development of renal dysfunction.51 This brings up the dilemma of whether to transfuse blood products or not, particularly as transfusion of more than four units of red blood cells is known to be a risk factor for renal impairment. Despite the lack of literature about this clinical practice, there are advocates for pre-operative optimization of haemoglobin levels. These controversies perhaps serve best to support the general use of blood-saving strategies aimed at reducing blood transfusion, wherever possible.

Furthermore, improving physical condition and so reducing frailty might be the best way to prepare patients. A profound pre-operative anamnesis with special regard to physical activity and the patient’s complaints, serves as a base for the so-called pre-habilitation. The latter means improving the patient’s physiological state before surgery, to prevent post-operative complications. In a recent review, Hulzebos et al.52 describe the possibilities for pre-operative optimization. Depending on the time frame and the individual’s complaints, a programme to strengthen peripheral muscles, cardiac performance and pulmonary function could be initiated. However, due to the nature of cardiac disease, the general condition is not always easily improved. The burden of a cardiac event impedes strenuous activities and endurance training so a customized programme could be necessary.

With regard to respiratory function, a pre-operative inspiratory muscle training regime was shown to reduce the incidence of post-operative pulmonary complications in a cohort of 655 patients undergoing elective CABG surgery.53 A Cochrane review by Katsura et al.54 based on 12 trials confirmed the findings from Hulzebos. As our group described recently in a review, only a few other measures could enhance pulmonary function after physiotherapeutic interventions. Pre-operative oral decontamination and subglottic suction to reduce bacterial load might reduce the chance of pneumonia. Uncertainty prevails about ventilation strategies such as lung protective ventilation and recruitment manoeuvres. The best policy might be reducing mechanical ventilation time (i.e. the philosophy of fast track anaesthesia) or even avoiding it by applying conscious sedation. Adequate post-operative pain relief facilitates better coughing and contributes to better pulmonary clearance while reducing surgical damage by avoiding pleurectomy sustains pulmonary mechanical function.55

Lastly, cardiac performance itself might be the final—but also most difficult—issue to improve. In a recent study, increasing haemoglobin by optimizing iron levels was shown to improve cardiac performance in 301 patients suffering from chronic cardiac failure. While the 6 min walking distance in the placebo group (n = 151) decreased over one year, it increased in the patients treated with iron infusion (n = 150).56 Pharmacological improvement of cardiac function could be attempted by the prophylactic administration of levosimendan.57 However, current data are not strong enough to legitamize making a conclusive recommendation.58

Selection criteria

Avoidance of the risk factors described above might be the best selection criteria. But this does not seem practical because it would restrict the eligible population dramatically. On the other hand, every patient could be seen as a fast track candidate, especially as some—such as the frail—could profit more from a quick pathway.

Ideally, the basic inclusion criteria are the type of procedure and duration of CPB (<150 min). These could be combined with a set of additive inclusion criteria according to a modified classification proposed by Mounsey and co-workers. They describe three groups of patients based on their risk with the fittest having a failure rate of <10%, the second best a failure rate of <20% and the poorest <40%. Moreover, these criteria should be checked continuously, because the course of the peri-operative process determines the feasibility of fast tracking (e.g. bleeding, length of operation and CPB, body temperature).

Scheduling the fittest patients first and the poorest last, could be advantageous in keeping a fast track programme running well. Following surgery, patients with a low risk could be sent directly to a post-anaesthesia care unit (PACU) where they would be extubated in a timely manner and optimized for discharge. If they have a failure rate of about 10% they will not frequently need an overnight stay. The same could apply to the medium risk group where the risk of ICU usage is increased. Finally, the patients with the poorest risk might be planned for the ICU with the option to discharge them in the event of success.

Patients with chronic kidney disease, low ventricular ejection fraction (<30%), a high degree of frailty, major neurological disease and COPD with a low 6-min walking test (below 150m) should be primarily planned for the ICU.39

Regardless of patient selection criteria, fast track pathways rely tremendously on an effective and dedicated team.16 That means the whole chain of care needs to be known and supported by each member having the mindset for individualized, tailored patient care, matched to the clinical needs.59 Despite the high degree of protocolling, the patient has to be at the centre of everybody’s attention.

Perspectives

The expectation is that technical developments will improve minimally invasive surgical procedures and cardiopulmonary bypass options in future. These could further reduce surgical trauma, leaving the patient with smaller incisions, less fluid shifts and fewer pulmonary complications. For example, percutaneous techniques enable the application of conscious sedation which might improve patient outcomes.16

Several interesting drugs are under investigation with regard to pharmacological opportunities to optimize organ protection.39 Levosimendan could preserve cardiac and also renal function, while statins were meant to prevent renal dysfunction.49,53

Another interesting method for pre-operative preparation of patients might be the provision of a carbohydrate rich diet peri-operatively, and also keeping fasting periods short. In fact, a recent review suggests this to be effective in general surgery.60

Conclusion

In the early fast track studies, it was shown that this technique is feasible and safe for selected patients and procedures. Although the limitations of fast tracking were later described, this did not stop further extension of patient and procedure selection criteria. Nowadays, fast track pathways are used to improve patient care. They are applicable to various surgeries, including single valve procedures and combined surgery, because of the development of surgical and bypass techniques which allow less invasive anaesthesia or conscious sedation. In principle, every patient could be treated as a fast track patient. Strategies which optimize the physiological condition of patients broaden the patient selection criteria. Current selection criteria should involve surgical parameters and the patient’s performance status, both of which should be continuously adjusted during the process. Most important is a concerted team approach with all contributors having the same mindset.

Table 1

Perioperative selection criteria

Author Year Patients (n=) Surigcal intervention Selection criteria 
Mounsey et al.25 1995 431 CABG low risk-1/2 VD or EF > 50% 
    intermediate risk 3 VD or EF < 50% or LVEDP>13 mmHg 
    poor risk 3VD and EF < 50% and LVEDP<13 mmHg 
Wong et al.26 1999 885 CABG age >75 year, gender, cardiac performance, renal function, bleeding, urgency of surgery 
Haanschoten et al.28 2012 5367 CABG, OPCAB, AVR, CABG +AVR physical status (ASA>3) 
    Exclusion: COPD>Gold2, EF < 35%, renal dysfunction, BMI>35 kg/m2, urgency, re-operation, CPB>150 min 
Constantinides et al.30 2006 1084 CABG cardiac performance, PVD, renal dysfunction, complexity of surgery, urgency 
Lee et al.31 2013 1645 open heart surgery cardiac performance, PVD, renal dysfunction, complexity of surgery, urgency 
Kiesling et al.32 2013 229 open heart operation physical status (ASA>3), cardiac performance, operation time>267 min 
   (no re-do, hypothermia, more than two valves)  
Author Year Patients (n=) Surigcal intervention Selection criteria 
Mounsey et al.25 1995 431 CABG low risk-1/2 VD or EF > 50% 
    intermediate risk 3 VD or EF < 50% or LVEDP>13 mmHg 
    poor risk 3VD and EF < 50% and LVEDP<13 mmHg 
Wong et al.26 1999 885 CABG age >75 year, gender, cardiac performance, renal function, bleeding, urgency of surgery 
Haanschoten et al.28 2012 5367 CABG, OPCAB, AVR, CABG +AVR physical status (ASA>3) 
    Exclusion: COPD>Gold2, EF < 35%, renal dysfunction, BMI>35 kg/m2, urgency, re-operation, CPB>150 min 
Constantinides et al.30 2006 1084 CABG cardiac performance, PVD, renal dysfunction, complexity of surgery, urgency 
Lee et al.31 2013 1645 open heart surgery cardiac performance, PVD, renal dysfunction, complexity of surgery, urgency 
Kiesling et al.32 2013 229 open heart operation physical status (ASA>3), cardiac performance, operation time>267 min 
   (no re-do, hypothermia, more than two valves)  

EF, Left ventricle ejection fraction; LVEDP, left ventricular end diastolic pressure; VD, vessel disease; CPB, cardiopulmonary bypass; BMI, body mass index; PVD, peripheral vessel disease.

Figure 1

Recommended selection criteria (modified according to Puri et al.39, Haanschoten et al.28, and Mounsey et al.25).

Figure 1

Recommended selection criteria (modified according to Puri et al.39, Haanschoten et al.28, and Mounsey et al.25).

Conflict of interest: none declared.

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