Extubation on the Operating Table in Pediatric Cardiac Surgery: A Multicenter Analysis of 986 Patients

Extubation on the operating table is increasingly utilized to minimize ventilator-associated complications and promote early recovery in pediatric cardiac surgery. However, its safety across diverse congenital heart disease (CHD) populations remains insufficiently defined. To evaluate the feasibility, safety, and clinical outcomes of on-table extubation across a broad spectrum of corrective and palliative congenital heart surgeries in children. This retrospective multicenter study included 986 pediatric patients (aged 7 days to 16 years) who underwent on-table extubation after CHD surgery between 2019 and 2025. Patients were grouped as corrective (n = 632) or palliative (n = 354) cases. Primary outcomes were reintubation and mortality. Secondary outcomes included ICU and hospital stay durations, and incidence of ventilator-associated pneumonia (VAP). Overall reintubation and mortality rates were 5.78 and 1.22%, respectively. Corrective procedures demonstrated significantly lower reintubation (4.11%) and mortality (0.63%) compared to palliative surgeries (8.76 and 2.26%, respectively; p < 0.01 and p < 0.05). Highest complication rates were observed in HLHS (reintubation and mortality 40%) and aortopulmonary shunt (53.13 and 21.88%). In contrast, Glenn and Fontan procedures showed low reintubation (1.69, 2.91%) and minimal mortality. No cases of VAP were reported. Mean ICU and hospital stays were 3.69 and 9.7 days. Of the 57 reintubation events, 23 (40.4%) occurred within 6 h of extubation, suggesting extubation failure, while 34 (59.6%) occurred between 6 and 24 h, potentially due to secondary complications. Early reintubations (0-6 h) were more common in aortopulmonary shunt (17 cases) and coarctation/IAA repair (3 cases), whereas later reintubations (6-24 h) predominated in ToF (5 cases), truncus arteriosus (4 cases), and TGA (3 cases). A moderate correlation was found between reintubation and mortality (Spearman's r = 0.45, p < 0.01). On-table extubation is a safe and feasible strategy in pediatric cardiac surgery, particularly in corrective procedures and select single-ventricle palliation. However, caution is warranted in high-risk physiologies such as HLHS and shunt-dependent circulation. Careful perioperative evaluation remains essential for optimal outcomes.