麻豆传媒

NEW ORLEANS -- Accelerated discharge from the hospital after elective cardiac surgery may not result in the most feared unintended consequences, according to one center's experience.

A review of patients who had cardiac surgery in 2004-2017 (excluding urgent and emergent cases) showed that early discharge, where the patient left the hospital within three days, was associated with:

• 0% 30-day mortality (same as with a longer hospital stay)

• 0% in-hospital major morbidity (vs 7%, P=0.001)

• 8% readmission within 30 days (vs 6%)

• 2% postoperative atrial fibrillation (Afib; vs 19%, P<0.001)

• 0% permanent pacemaker implants (vs 1%)

Short lengths of stay are therefore "very safe," and the present data can be used to reassure patients that it's okay to go home early, said S. Chris Malaisrie, MD, of Northwestern Medicine in Chicago, during a press conference here at the Society of Thoracic Surgeons (STS) meeting.

Reducing the time a patient spends in the hospital is part of an Enhanced Recovery After Surgery (ERAS) protocol, a large, multidisciplinary care initiative with the goal of improving overall patient outcomes.

ERAS is a bundle of protocols spanning the various phases of the patient's care, from the preoperative (education for the patient, diet, and exercise) to the postoperative (reduced opioids, transition to home), explained Daniel Engelman, MD, of Baystate Medical Center in Springfield, Massachusetts, and president of the ERAS Cardiac Society, which is working with STS to support the rollout of the program.

Worries about the ERAS program are about whether it's just about getting the patient out of the hospital sooner, Engelman said at the press conference: "It's not. It's an evidence-based program that gets them out at the right time. If it's done the way it was done at Northwestern, it can be done without increasing complications," he emphasized.

"Despite how much [time we] spend discussing how we operate on patients, 80% of morbidity and mortality after cardiac surgery actually occurs outside of the operating room. That includes patients who are inadequately prepared for surgery: they aren't given proper nutrition, they haven't quit smoking ... [or gotten] alcohol under control," he said.

Study Details

For the study, Malaisrie and colleagues found that patients stayed a median of six days in the hospital after cardiac surgery at Northwestern. Out of nearly 6,000 people, just 2.2% had a 3-day length of stay or less. After 1:3 propensity score matching, the investigators compared the outcomes of 121 short-stay patients and 357 longer-stay peers.

The two groups shared similar baseline characteristics: younger age (average 51 years), predominantly men, and very low surgical risk (STS score 0.4%). The most common surgeries undertaken were mitral valve repairs, isolated coronary artery bypass grafting, and isolated aortic valve replacements.

These data cannot determine causality between early discharge and postoperative Afib, Malaisrie cautioned.

Nevertheless, "if you have a patient with preop Afib, most cardiac surgeons are aggressive at treating Afib at the time of cardiac surgery [with Afib ablation that has] up to a 90% success rate and 80% chance of eliminating anticoagulation in the long term. If we identify these patients early, it shouldn't impact their length of stay. We can still get them out in three days," he told the audience.

The study also limited the conclusions that could be drawn about patients who need to go under the knife urgently or in an emergent fashion -- dissections or acute heart attacks, for example -- Malaisrie said. "We're going to exclude these urgent patients from our ERAS program."

Engelman had a different perspective: For those patients, there wouldn't be the preoperative component, but the perioperative and postoperative initiatives may still be valid. "I believe every patient is a candidate for postop ERAS," he said, adding that reducing opioids and using multimodal anesthesia are "low-hanging fruit."

ERAS protocols are ubiquitous in Europe, and most major programs in North America are in some stage of adopting them, Engelman noted.

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