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Enhanced Recovery After Cardiac Surgery: Sternotomy Vs Minimally Invasive Approach
Joshua S. Newman1, Shelby Shamir
2, Omar A. Jarral
2, Derek R. Brinster
2, Stevan S. Pupovac
1, S. Jacob Scheinerman
2, Nirav C. Patel
2.
1Northwell Health, New York, NY, USA,
2Lenox Hill Hospital / Northwell Health, New York, NY, USA.
BACKGROUND:Enhanced recovery after cardiac surgery (ERACS) attempts to improve outcomes and decrease hospital and intensive care length of stay. Similarly, minimally invasive approaches are being employed. Limited data exists focusing on the impact an ERACS program has on traditional sternotomy vs minimally invasive coronary surgery.
METHODS:A retrospective review was performed on patients undergoing coronary bypass via traditional sternotomy and robotic assisted approaches before and after implementation of an ERACS program. Prior to ERACS, 94% (n = 891) of patients underwent sternotomy and 6% (n = 55) minimally invasive approach. After ERACS implementation, 72% (n = 237) underwent sternotomy and 28% (n = 90) a minimally invasive approach. Primary outcomes were differences in postoperative intensive care unit and hospital length of stay, total morphine milligram equivalents (MME) and hours intubated. A logistic regression was performed to assess the impact of the ERACS protocol on different surgical approach.
RESULTS:After ERACS implementation, significant reductions in the rate of new onset atrial fibrillation (AF) and opiate administration decreased by 6.5% (p = 0.029) and 12.38 MME (p = 0.006), respectively. Furthermore, hours intubated (9.2 vs 6.0, p = 0.526), intensive care hours (64.1 vs 64.2, p = 0.725), and post operative days (5.48 vs 5.03, p = 0.275) trended down. Assessing the impact of sternotomy, trends towards decreased new onset AF (23.4% vs 30.1%, p = 0.121), MME (51.8 vs 57.4, p = 0.887), and hours intubated (3.1 vs 9.0, p = 0.060) were observed in the minimal access cohort, with significant decreases in intensive care hours (45.0 vs 66.6, p < 0.001) and post operative days (4.4 vs 5.5, p = 0.007).ERACS protocol had a greater impact on new onset postoperative AF for patients without a sternotomy (p < 0.001); however, the improvements were similar between approaches for the remaining metrics (p > 0.05).
CONCLUSIONS:Minimally invasive approaches and ERACS protocols both improve patient outcomes independently. The impact of an ERACS protocol is synergistic with minimal access surgery; however, ERACS demonstrated improvements in all comers.
Legend: Table 1: Outcome Data
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