Ultra-fast-track perioperative pathway versus conventional general anesthesia in elderly patients undergoing minimally invasive cardiac surgery: a retrospective single-center propensity score-matched study

Ultra-fast-track anesthesia (UFTA) has been increasingly used in adults undergoing minimally invasive cardiac surgery (MICS), but evidence in elderly patients remains limited. We evaluated the feasibility and clinical outcomes of UFTA compared with conventional general anesthesia (CGA) in elderly patients undergoing MICS. We conducted a retrospective study of patients aged ≥ 65 years who underwent MICS at our center between January 2022 and December 2024. Patients were categorized into a UFTA-based perioperative pathway group, in which extubation was performed in the operating room within 1 h after surgery when predefined criteria were met, and a CGA group, in which extubation occurred in the ICU. The primary endpoint was postoperative length of stay (LOS). Secondary endpoints were: ICU stay duration, duration of inotropic and vasoactive support, time to extubation, major postoperative complications, and 30-day outcomes. Of the 584 cases that met the inclusion criteria, 430 were successfully matched at a 1:1 ratio, resulting in two well-balanced groups of 215 patients each. In the matched cohort, patients managed with the UFTA-based perioperative pathway had a shorter postoperative LOS (median [IQR], 8 [7–11] vs. 9 [7–12] days; mean ratio 0.889 [95% CI 0.803–0.985]; P = 0.025), shorter ICU stay (26 [22–45] vs. 46 [28.5–72] hours; mean ratio 0.641 [95% CI 0.441–0.933]; P = 0.020), and shorter duration of inotropic and vasoactive support (2 [1–2] vs. 3 [2–4] days; mean ratio 0.570 [95% CI 0.486–0.669]; P < 0.001). Time to extubation was markedly shorter in the UFTA group (10 [5–15] vs. 630 [540–1020] minutes; mean ratio 0.015 [95% CI 0.013–0.018]; P < 0.001). Respiratory insufficiency and delirium were less frequent in the UFTA group, although these secondary complication findings should be interpreted cautiously. In this propensity score-matched cohort of elderly patients undergoing MICS, the UFTA-based perioperative pathway was feasible and was associated with shorter postoperative LOS and ICU stay, as well as a shorter duration of pharmacologic hemodynamic support. Further prospective multicenter studies with standardized outcome assessment are needed to confirm these findings and to better define appropriate candidates.