Enhanced Recovery After Surgery (ERAS) in Cardiac Surgery: From Evidence to Precision Perioperative Medicine

Cardiac surgery is increasingly performed in older, frailer patients with multimorbidity, making postoperative recovery dependent not only on technical success but also on the quality of perioperative care. Enhanced Recovery After Surgery (ERAS) programs address this challenge through coordinated preoperative optimization, attenuation of surgical stress, organ protection, opioid-sparing analgesia, early mobilization, and structured discharge. This narrative review critically appraises ERAS in cardiac surgery and organizes the evidence across the perioperative pathway. Available studies associate complete ERAS programs with modest reductions in intensive care and hospital length of stay and possible reductions in overall complications, but evidence certainty is limited by heterogeneous bundles, single-center designs, and predominance of observational studies. Component-level evidence is strongest or clinically most relevant for frailty assessment, Patient Blood Management, multimodal analgesia, oxygen delivery-guided perfusion, delirium prevention, and early mobilization, although universal thresholds and isolated technologies should be avoided. Successful implementation depends on multidisciplinary governance, explicit responsibilities, adherence measurement, audit, and patient-centered outcomes. Future development should retain a standardized core while allowing transparent adaptation to baseline risk and observed response. Precision perioperative approaches remain hypothesis-generating and require external validation, clinical impact evaluation, assessment of equity, and demonstration of cost-effectiveness before routine adoption.