Ultra-fast Track Research Articles

One-year outcomes of surgical aortic valve replacement: a single, high-volume center experience

The introduction of transcatheter aortic valve replacement (AVR) mandates attention to outcomes after surgical AVR (SAVR). The aim of this study was to assess 1-year outcomes in a contemporary large cohort of patients undergoing AVR. Data from 520 patients who underwent isolated SAVR between October 2016 and April 2019 were prospectively collected. The mean age of the study population was 72.8 ± 10.1 years and the average EuroSCORE II was 1.8 ± 1.5%. SAVR was performed using minimally invasive approaches (MI-AVR) in 306 patients (58.9%). However, the rate of MI-AVR considerably increased over the observational period from 47.9% to 86.7% (p<0.001). MI-AVR patients received rapid deployment valves in 40% of cases, minimally invasive extracorporeal circulation system in 34.4% and ultra fast track anesthetic management with table extubation in 38.2%. Overall 30-day mortality was 0.4% (n=2). The rates of postoperative stroke and atrioventricular block requiring pacemaker implantation were 0.6% (n=3) and 3.8% (n=20), respectively. At 1 year, the estimated survival, stroke and rehospitalization rates were 97.3%, 1% and 4.5%, respectively. Overall, the estimated incidence of the composite endpoint - death, stroke and rehospitalization - was 7%. Contemporary SAVR in a high-volume center yields excellent clinical outcomes with very low mortality and morbidity. In this setting, the extensive use of minimally invasive approaches combined with the modern techniques and technologies demonstrated to improve clinical outcomes and increase patient and family satisfaction.

Benefits of Ultra-Fast-Track Anaesthesia after HeartMate 3 Implantation: A Pilot Study

Purpose Avoidance of invasive ventilation after cardiac surgery is an attractive method to reduce the length of hospital stay and related complications. However there is limited experience about ultra-fast track anaesthesia (UFTA) in patients with end stage heart failure after left ventricular assist device (LVAD) implantation. This study aimed to investigate the outcomes of UFTA with extubation in operating theatre in patient receiving HeartMate 3 (HM3) implantation. Methods This study was an observational study. Between October 2015 and December 2017 all elective eligible patients for HM3 implantation in our department were included in this study. Exclusion criteria for UFTA were, inter alia, INTERMACS 1 and 2, preoperative invasive ventilation or forced expiratory volume in 1 second (FEV1) Results 45 patients received HM3 implantation in the mentioned period and 36 patients were eligible for UFTA. UFTA was successfully performed in 27.7 %. Distribution of preoperative risk factors was similar between groups. Patients in UFTA group had significantly lower incidences of pneumonia (p =0.001), septic shock (p=0.045) and right ventricular failure (RVF) (p=0.024). They showed a significantly higher cardiac index in the first 24h. (p=0.012); a significantly lower central venous pressure during the first 24h. postoperatively (p=0.005) and a significantly better central venous saturation after the first 6h postoperatively and continuing to 24h postoperatively (p=0.011). Additionally, intensive care unit (ICU) stay (p=0.006) was significantly shorter in the UFTA group. Kaplan-Meier analysis revealed no significant difference in the 30-days survival. Conclusion In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in HM3 patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, and shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective investigations are encouraged to evaluate the capability of UFTA for sustainable protection of right ventricular function, and these studies should aim to identify useful criteria for adequate patient stratification.

OC06 BUILDING UP A MULTIDISCIPLINARY 360° MINIMALLY INVASIVE PROGRAM FOR AVR: OUR EXPERIENCE

Aim: The aim of this study was to report the first results of our multidisciplinary minimally invasive program to treat patients who require aortic valve replacement (AVR), which involves: 1) reduced chest incision (through upper ministernotomy or right anterior minithoracotomy), 2) sutureless or rapid deployment AVR, 3) minimally invasive extracorporeal circulation (MiECC) system and 4) ultra fast-track (UFT) anaesthesia. Methods: Data from 167 consecutive patients undergoing primary isolated aortic valve replacement through minimally invasive approaches (MIAVR) between October 2016 and April 2018 were prospectively collected. The mean age of the study population was 74 ± 9 years, and the average EuroSCORE II was 2.1 ± 1.2. Results: MIAVR was performed using sutureless or rapid deployment valves in 76 (45.5%) patients, MiECC system in 63 (37.7%), and UFT management in 67 (40.1%). Overall in-hospital mortality was 0.6% (n = 1). The rate of postoperative stroke and atrioventricular block requiring pacemaker implantation was 1.2% (n = 2) and 3.6% (n = 6), respectively. MiECC system was associated with reduced postoperative bleeding (requiring chest re-opening) compared with conventional cardio-pulmonary bypass circuits (0% vs. 5.8%, p = 0.05). The mean intensive care unit stay was 25 hours in UFT patients and 52.2 hours in no-UFT patients (p = 0.04). Hospital stay was similar between groups (UFT 6.9 days, no-UFT 13.9 days, p = 0.2). Conclusions: Our UFT mini AVR program is a multidisciplinary minimally approach that involves the latest best technologies and techniques for AVR. We believe it may considerably increase patient's comfort being associated with faster recovery and excellent hospital outcomes.

VD16 SUTURELESS MINIAVR WITH RIGHT ANTERIOR THORACOTOMY AND ULTRA FAST TRACK ANAESTHESIA: OUR MULTIDISCIPLINARY APPROACH IN ANCONA

Abstract While anatomical and clinical indications to transcatheter aortic valve interventions are expanding, surgical aortic valve replacement continues to progress as demonstrated by improving clinical outcomes in contemporary patients’ cohorts. However, mainly due to the availability of significantly less invasive trans-catheter cardiac interventions, patients’ expectations have dramatically changed in the last decade with reduced trauma and fast recovery being now strongly valued. An increasing employment of minimally invasive multidisciplinary approaches that call surgeons, anaesthesiologists, perfusionists, nurses and physiotherapists to more efficacious collaborative efforts becomes so crucial to minimize surgical invasiveness as well as to decrease the psychological impact of surgery and fasten patient's return to pre-operative lifestyle. With this video we would like to share our multidisciplinary approach to aortic valve replacement. This involves a right anterior mini-thoracotomy, the implantation of a sutureless Livanova Perceval S valve and ultra fast track anaesthetic protocols.

Effect of aminophylline on efficacy of extubation under ultra-fast track anesthesia in pediatric patients with congenital heart disease undergoing surgical correction of anomaly

Objective To evaluate the effect of aminophylline on the efficacy of extubation under ultra-fast track anesthesia (UFTA) in pediatric patients with congenital heart disease (CHD) undergoing surgical correction of anomaly. Methods Ninety American Society of Anesthesiologists physical status Ⅰ or Ⅱ pediatric patients, aged<6 yr, undergoing surgical correction of anomaly, were randomized into 3 groups (n=30 each)using a random number table method: group Ⅰ, group Ⅱ and group Ⅲ.After the end of surgery, normal saline was given in groupⅠ, 1 mg/kg aminophylline was given in groupⅡ, and 2 mg/kg aminophylline was given in group Ⅲ.The condition of extubation in the operating room and respiratory rate at extubation were recorded.Mean arterial pressure, heart rate and bispectral index value were recorded at the end of surgery, and at 9 and 15 min after administration. Results Compared with groupⅠ, the rate of successful extubation in the operating room, BIS value at 9 min after administration and respiratory rate at extubation were significantly increased inⅡand Ⅲ groups (P 0.05). Conclusion Aminophylline can increase the efficacy of extubation under UFTA in pediatric patients with CHD undergoing surgical correction of anomaly, and 1 mg is the recommended dose. Key words: Aminophylline; Heart defects, congenital; Anesthesia; Trachea

Early Experiences with Ultra-Fast-Track Extubation after Surgery for Congenital Heart Disease at a Single Center.

BackgroundEarly extubation after cardiovascular surgery has some clinical advantages, including reduced hospitalization costs. Herein, we review the results of ultra-fast-track (UFT) extubation, which refers to extubation performed on the operating table just after the operation, or within 1–2 hours after surgery, in patients with congenital cardiac disease.MethodsWe performed UFT extubation in patients (n=72) with a relatively simple congenital cardiac defect or who underwent a simple operation starting in September 2016. To evaluate the feasibility and effectiveness of our recently introduced UFT extubation strategy, we retrospectively reviewed 195 patients who underwent similar operations for similar diseases from September 2015 to September 2017, including the 1-year periods immediately before and after the introduction of the UFT extubation protocol. Propensity scores were used to assess the effects of UFT extubation on length of stay (LOS) in the intensive care unit (ICU), hospital LOS, and medical costs.ResultsAfter propensity-score matching using logistic regression analysis, 47 patients were matched in each group. The mean ICU LOS (16.3±28.6 [UFT] vs. 28.0±16.8 [non-UFT] hours, p=0.018) was significantly shorter in the UFT group. The total medical costs (182.6±3.5 [UFT] vs. 187.1±55.6 [non-UFT] ×100,000 Korean won [KRW], p=0.639) and hospital stay expenses (48.3±13.6 [UFT] vs. 54.8±29.0 [non-UFT] ×100,000 KRW, p=0.164) did not significantly differ between the groups.ConclusionUFT extubation decreased the ICU LOS and mechanical ventilation time, but was not associated with postoperative hospital LOS or medical expenses in patients with simple congenital cardiac disease.

P01-3 - Multicenter survey on the practice of ultra-fast track anaesthesia in paediatric cardiac surgery

Ultra-fast track extubation (defined as On table extubation [OTE] of the patient in the operating room) has been advocated in adults, with however controversial effects on outcomes. [1,2] We aimed to assess a current status of strategies for post-operative extubation in paediatric patients undergoing surgery for congenital heart disease in different countries. The principal goals of the survey were to describe global practice for fast track paediatric cardiac anaesthesia including OTE and to learn from international experience of OTE practice.

Ultra fast track surgery: a rapid deployment aortic valve replacement through a J-ministernotomy.

Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.

Ultra fast track mini AVR: going beyond reduced incisions

Ultra fast track mini AVR: going beyond reduced incisions

Ultra fast track anaesthetic management

Ultra fast track anaesthetic management

Perioperative Risk Factors and Predictive Model Proposal of Ultra-Fast-Track Failure and Prolonged Hospital Length of Stay in a Preliminary Protocol of Enhanced Recovery after Off-Pump Coronary Artery Bypass Grafting by Left Anterolateral Thoracotomy Approach (ERAS)

Background: The use of Ultra-fast-track (UFT) management in cardiac surgery may shorten hospital length of stay (Hosp-LOS) when is part of a protocol of enhance recovery after surgery (ERAS). Methods: We retrospectively analyzed the data of the patients undergoing elective off-pump coronary artery bypass grafting (OPCAB) using UFT under a pilot program of ERAS at a Venezuelan nonprofit cardiac center from 2010 to 2014. The primary goal was to describe the short-term outcome of a consecutive case-series managed with desfluraneremifentanil- intercostals nerve block for OPCAB by Left-Anterolateral Thoracotomy and followed up by multidisciplinary enhance recovery pathway. The secondary goals were to identify perioperative predictors for UTF-failure and Hosp-LOS >4 days and try to propose a predictive risk model from the variables involved. Results: 1,943 bypasses were performed on 673 patients. 61.5 ± 9.5 years old, EuroSCORE was 5.2 ± 4.1. 97.8% was extubated in Operating Room (UFT-success) and 2.2% extubated in the intensive care unit (UFT-failure). The reintubation rate was 0.5%. Patients had an Intensive Care Unit length of stay (ICU-LOS) of 29 ± 4.2 hours; 636 patients (94.5%) had ICU-LOS ≤ 24 h, 2.1% readmitted to ICU. The Hosp-LOS after discharge from ICU was 50.5 ± 9.9 hours, 633 (94.1%) had Hosp-LOS ≤ 4 days. Univariate analysis revealed as independent risk factors for UFT-failure: age, female sex, EuroSCORE, Severity of Angina Pectoris, EF 4 hrs, (AOR=157.5) (95%CI) (p 4 days : Age>80 y-old, female sex, NYHA>III, EuroSCORE, severity of Angina pectoris , EF 4 days) : Redo (AOR=7.68) (95%CI), t-Qx>3 hrs (AOR>74) (95%CI) (p 24 hrs (AOR=29.3) (95%CI) (p<0.001). Conclusions: As most patients were extubated in the Op.Room, had short ICU-LOS ( 80 y.o , female sex, severity of EuroSCORE and ≥ 2 PRBCs transfusion were risk factor for UTF-failure and prolonged Hosp-LOS. However, the stronger predictive factors for UTF-failure and Hosp-LOS>4 days were transfusion of ≥ 2 PRCB, Redo, duration of surgery >3 h and ICU-LOS >24 h. Prospective studies would better elucidate the risk factors for longer Hospital-LOS and attendant morbidities.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization.

Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

P868Current safety of pulmonary vein ablation: feasibility of ultrafast track discharge

P868Current safety of pulmonary vein ablation: feasibility of ultrafast track discharge

Apport du Walant dans la chirurgie échoguidée du syndrome du canal carpien, une nouvelle approche hyper-ambulatoire

Carpal tunnel syndrome is commonly treated by a mini-open or endoscopic procedure. It has been demonstrated that an ultrasound guidance permits assessment of a precise anatomical diagnosis in of the carpal tunnel, avoiding nervous lesions, and controlling the complete release of the median nerve. The aim of this study is to evaluate the feasibility and the advantages of a wide-awake technique and thus to validate an original ultra fast track procedure for patient who suffer of a carpal tunnel syndrome. In a prospective study, 100 people (15 men and 85 women, mean age 62 years old) were treated between November 2015 and May 2015 with an ultrasound-guided percutaneous procedure by two surgeons. All the patients have had a clinical examination and a conduction study. None of the patient was fasting. The procedure has been performed for all patients with a modified wide-awake protocol of anesthesia (local anesthesia with epinephrine, associated with a median nerve blockade at the wrist) and without tourniquet named Wide Awake Local Anesthesia with No Tourniquet (WALANT). None received a sedation. The carpal release was performed with a Kemisy knife (NewClip Technics™, France). The progression of the knife was controlled with the high frequency ultrasound probe (6–15 MHz). A picture of the knife through the retinaculum was taken as evidence of the complete release. All the patients go directly to the nursing ward and are allowed to leave this unit after 15 min. Time to leave the unit of hand surgery was noted. Results All the patients have had a good clinical result. None of them complained of any pain during de procedure. There was no nervous injury. All the clinical parameters were the same compared to traditional carpal tunnel release. None of the patients complained about reflex sympathetic dystrophy. The mean duration time to leave was 32 min (15–68). In conclusion, the study emphases that ultrasound guide carpal tunnel release is a safe method. Moreover, this surgery may be done without tourniquet and with a limited anesthesia. Patients have had an immediate functional recovery of the hand that allowed to spend a very short time in the day surgery ward. Further study could be assessed to point out the possibility to reduced drastically the cost of the carpal tunnel syndrome with the use of an ultra fast track procedure allowed by ultrasound guided surgery with wide awake plus approach.

Application of ultra-fast track anesthesia in patients undergoing total thoracoscopic closure of congenital heart defects

Objective To investigate the safety and feasibility of immediate extubation after total thoracoscopic closure of atrial or ventricular septal defects.Methods Clinical and operational data of 286 patients were retrospectively analyzed.Atrial or ventricular septal defects were closed via a totally thoracoscopic approach.Summary the feature of anesthesia,operation,cardiopulmonary bypass and immediate extubation,postoperative outcomes of the patients.The patients were divided into two groups:OR group and ICU group according to the time of extubation.The general characteristics,clinical and operation data were recorded and compared between two groups.Results All the operations were successful and all patients were alive.Immediate extubation in the operating room was performed in 220 (76.9％) patients,in which 2 (0.9％) patients was performed re-intubation in the operating room within 15 min of the initial extubation.A delayed extubation was completed in the intensive care unit in the remaining 66 patients.There was no significant difference in the age,sex,body weight,or type of congenital heart defect between two groups.However,the preoperational mean pulmonary arterial systolic pressure (PASP) was higher in the ICU group [(50±10) mmHg(1 mmHg=0.133 kPa)]than that in OR group [(45±8) mmHg] (P＜0.05),and more patients in the ICU group had severe preoperational pulmonary hypertension [14 vs 6(P＜0.05)].The total dosage of fentanyl used during the surgery was lower in the OR group [(10±4) μg/kg vs (6±4) μg/kg (P＜0.05)].However,there was no significant difference in the dosage of fentanyl per unit time between two groups.The cardiopulmonary bypass time,aortic cross clamp time,total duration of the surgerywere shorter and the dosage of fentanyl used during the surgery was lower in the OR group(P＜0.05).In OR group,the rates of postoperative sedation and analgesic were shorter than those in ICU group.There was no death and major complications in all patients.Conclusions Immediate extubation was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of atrial or ventricular septal defects.Preoperational pulmonary hypertension,duration of the surgery,and the dosage of fentanyl used for were the influence factors during the surgery immediate extubation. Key words: Thoracoscope; Cardiac surgery; Ultra-fast track anesthesia; Immediate extubation

Ultra fast track anaesthesia for patients scheduled for robotic totally endoscopic coronary artery bypass is feasible and safe

Imbault, J.1; Zaouter, C.1; Champion, S.1; Coiffic, A.1; Labrousse, L.2; Ouattara, A.1 Author Information

Pro: Early Extubation Following Surgery for Congenital Heart Disease

EARLY EXTUBATION in adult patients undergoing cardiac surgery has been shown to be safe and to decrease resource use. 1 Myles P.S. Daly D.J. Djaiani G. et al. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology. 2003; 99: 982-987 Crossref PubMed Scopus (45) Google Scholar , 2 Cheng D.C. Fast track cardiac surgery pathways: Early extubation, process of care, and cost containment. Anesthesiology. 1998; 88: 1429-1433 Crossref PubMed Scopus (135) Google Scholar , 3 Cheng D.C. Karski J. Peniston C. et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: A prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996; 112: 755 Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar , 4 Cheng D.C. Fast-track cardiac surgery: Economic implications in postoperative care. J Cardiothorac Vasc Anesth. 1998; 12: 72-79 Abstract Full Text PDF PubMed Scopus (89) Google Scholar Despite several large studies showing that this practice can be extended to pediatric patients undergoing surgery for congenital heart disease (CHD), there is still a significant amount of controversy. Some centers attempt extubation as soon as possible, whereas others routinely sedate patients after surgery. A quick literature search shows that early extubation in children undergoing surgery for CHD had been introduced in the late 1970s. 5 Barash P.G. Lescovich F. Katz J.D. et al. Early extubation following pediatric cardiothoracic operation: A viable alternative. Ann Thorac Surg. 1980; 29: 228-233 Abstract Full Text PDF PubMed Scopus (86) Google Scholar , 6 Schuller J.L. Bovill J.G. Nijveld A. et al. Early extubation of the trachea after open heart surgery for congenital heart disease A review of 3 years' experience. Br J Anaesth. 1984; 56: 1101-1108 Crossref PubMed Scopus (64) Google Scholar , 7 Heard G.G. Lamberti J.J. Park S.M. et al. Early extubation after surgical repair of congenital heart disease. Crit Care Med. 1984; 13: 830-832 Crossref Scopus (48) Google Scholar Several large studies and case series have since proved that early extubation can be performed safely in simple and complex surgical cases for all age groups, including neonates. 8 Mittnacht A.J. Thanjan M. Srivastava S. et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg. 2008; 136: 88-93 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 9 Kloth R.L. Baum V.C. Very early extubation in children after cardiac surgery. Crit Care Med. 2002; 30: 787-791 Crossref PubMed Scopus (69) Google Scholar , 10 Heinle J.S. Diaz L.K. Fox L.S. Early extubation after cardiac operations in neonates and young infants. J Thorac Cardiovasc Surg. 1997; 114: 413-418 Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar , 11 Vricella L.A. Dearani J.A. Gundry S.R. et al. Ultra fast track in elective congenital cardiac surgery. Ann Thorac Surg. 2000; 69: 865-871 Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar , 12 Neirotti R.A. Jones D. Hackbarth R. et al. Early extubation in congenital heart surgery. Heart Lung Circ. 2002; 11: 157-161 Abstract Full Text PDF PubMed Scopus (60) Google Scholar The term “early extubation” typically is applied when patients are extubated within 6 to 8 hours after surgery but also includes extubation in the operating room (OR) at the end of the surgical procedure. Early extubation typically is part of a fast-tracking regimen with the goal of early patient mobilization and intensive care unit (ICU) and hospital discharge, with benefits that are well documented and that will be discussed in detail below.

623 Ultra fast track cardiac surgery and anaesthesia: A collaborative team approach

The advantages of minimally invasive coronary artery bypass grafting (CABG) surgery over conventional CABG include shorter recovery time, overall reduction in morbidity, blood transfusion, greater patient satisfaction, shorter hospital stay, and earlier return to work. In order to explore the opportunities within our practice to improve patient care while at the same time protecting our patients from harm and reducing costs to our financially challenged hospitals, we identified an opportunity to explore the option of bypassing the intensive care unit (ICU) in a highly selected group of patients undergoing minimally invasive coronary artery bypass surgery. This was accomplished through an extensive collaboration between nurses, administrators and physicians alike. A collaborative pathway was constructed for selection of suitable patients by the surgeon and anaesthesiologists based on the grounds of compatible coronary anatomy for minimally invasive coronary artery revascularization. Secondary factors included minimal systemic co-morbidity. A total of 14 patients underwent successful fast track cardiac surgery. There were 12 males and 2 females. They all received preoperative spinal injection of 15 mg of bupivacaine and 3 to 5 mcg/kg of preservative free morphine prior to their general anaesthesia. Using single lung ventilation they underwent Robotic-assisted CABG. Immediately after the revascularization they underwent cardiac catheterization to confirm patency of their graft and simultaneous percutaneous coronary intervention in 2 patients in the hybrid operating suite. Simultaneously, their anaesthetic and neuromuscular blockade was reversed achieving spontaneous respiration. Following clinical confirmation of return of spontaneous respiration, wakefulness and protective airway reflexes, the endotracheal tube was removed, and the patients were transferred to the post anaesthetic care unit (PACU). All patients were monitored in the PACU for 4 to 6 hours before being transferred to the postoperative ward. One patient had to return to the operating room for increase bleeding after 3 hours. He underwent uncomplicated exploration for chest wall bleeding. All patients had patent grafts, no post-operative complications and were extremely satisfied on discharge. Average length of stay in hospital was 3.1 ± 0.78 days. We believe Ultra fast track cardiac surgery is a safe and efficient way to conduct cardiac surgery in a highly selected group of patients. The importance of collaboration and a team based approach cannot be emphasized enough. We anticipate expanding this program within our own institution and look forward to evaluating the cost effectiveness of avoiding the ICU.

Para-vertebral block versus epidural anesthesia in ultra fast track cardiac surgery

INTRODUCTION: Epidural anesthesia provides superior analgesia, better respiratory outcome and myocardial protection after cardiac surgery (1,2) but is at risk of epidural hematoma. Paravertebral block related hematoma may have less consequences and anesthesiologists may feel more comfortable with this technique. The aim of this study is to compare the analgesia provided by high thoracic epidural analgesia (Epidural group) versus single-shot para-vertebral blocks (PVB group) after cardiac surgery using an ultra-fast track strategy.