Enhanced recovery after cardiac surgery: gender insights from an ultra-fast-track protocol

OBJECTIVES: Ultra-Fast-Track (UFT) Enhanced Recovery After Surgery (ERAS)-defined by on-table extubation, minimally invasive surgical technique and deescalated ICU care-represents an intensified ERAS approach. Female patients remain underrepresented in cardiac surgery research and experience worse postoperative outcomes. Therefore, we investigated possible gender-mediated differences in the outcomes of our UFT-ERAS program. METHODS: 800 consecutive patients underwent UFT-ERAS for minimally invasive valve and aortic surgery at our institution 01/2021-09/2024. Patients were divided by gender and retrospective cohort analysis was performed. The primary outcome was UFT-ERAS achievement, defined by a 0-5 score of postoperative milestones (on-table extubation, postoperative intermediate care, early physiotherapy, transfer to general ward ≤24 h and hospital discharge ≤7 days). Secondary end-points were Major Adverse Cardiovascular Events (MACE), reoperation for bleeding, reintubation, ICU readmission, acute kidney injury, atrial fibrillation, delirium and transfusion. RESULTS: Women were older and had higher baseline risk scores. Overall ERAS adherence and major postoperative complications were comparable between sexes. Only discharge ≤7 days was less frequent and postoperative transfusion need more frequent in women. In multivariable ordinal logistic regression adjusting for STS-PROM, age, and procedure type, sex was not independently associated with ERAS achievement (OR 0.88, 95% CI 0.66-1.18). CONCLUSIONS: In this predominantly low-risk patient cohort within a UFT-ERAS pathway, sex was not independently associated with overall ERAS achievement. However, women more frequently required transfusion and were less likely to be discharged within 7 days.