Foreword: Fast track in aortic valve surgery

‘Fast track’ in cardiac surgery includes early extubation, a short stay in the intensive care unit, and early discharge from the hospital.1 Although several centres were familiar with an early extubation of selected low-risk cardio-surgical patients in the odds ratio , the term ‘Fast Track’ was first coined in the 1990s.2 Limited resources were the main driving force for the development of more standardized fast track protocols when huge cardiac programs of more than 10 surgical cases a day required reliable intensive care unit (ICU) capacities. In most cardiac centres, so called intermediate care units (IMC) were established in these days also, to improve the ‘flow’ of patients and close the gap between ICU and care in a standard ward. The comprehensive care in intermediate care units with extended monitoring and specialized staff, usually in a 1–4 nurse-patient ratio, made early extubation and avoidance of the ICU for low risk cardio-surgical patients, notably CABG in younger ages, possible.3–6 The evolution of less invasive techniques in cardiac surgery, such as the off-pump coronary bypass surgery, further stimulated the fast track programs, which not only benefitted patients but also aimed to improve the cost effectiveness of cardiac surgical programs.7 Nowadays, cardiac surgery is faced with an increasing number of elderly, frail, and comorbid patients. The number of complex surgical cases is increasing; hence, the demand on long-term ICU care is increasing. Not only are the capacities of the ICU limited, the same is true for the intermediate care wards, which are blocked by more comorbid and infirm patients. It is a paradox that rather healthy and stable patients spend more time in ICU and IMC than needed although early extubation and a discharge to a lower level care ward would be feasible. In daily practice, a lot of patients lose time before they are transferred to a standard care ward, which offers more comfort and privacy and accelerates the rehabilitation process. And, of course, this would save some money too. As the result of this evolution, some centres have recently established specialized Post Anesthesia Units (PACU), which is comparable to a traditional recovery unit after anesthesia and other kinds of surgical procedures that require a defined time of post-operative observation before transferring the patient to a standard ward. This unit provides extended monitoring and specialized staff members.8 With such a concept, low-risk patients could be extubated within 3–6 h after cardiac surgery, and then a decision is made about which level of care is necessary for the next 24 h. A unit with these features is appealing for the new transcatheter valve procedures, i.e. Transcatheter aortic valve implantation (TAVI) and interventional mitral valve procedures, since these procedures allow a very short intubation time and even isolated sedation strategies for elderly and frail patients.9 Cardiac surgeons are confronted with this evolution in many aspects. Although they are part of most TAVI programs, it is expected that the number of conventional aortic valve procedures will decline. The gap between a conventional valve surgery with full sternotomy and several days in ICU and IMC and transcatheter valve therapy with sedation therapy and early recovery is obvious. Even if open-heart valve replacement demonstrated a more sustainable result, patients would request a less invasive and more comfortable treatment. It is up to cardiac surgeons to reengineer conventional aortic valve replacement. Why should it not be possible to achieve an early extubation after conventional aortic valve replacement? Is the classical intensive care unit of today as depicted above necessary in the majority of aortic valve replacement (AVR) patients? This questions calls for a rapid response. By definition, fast track in cardiac surgery means an early extubation <3 h, planned intensive or intermediate care unit discharge > 18 h, and early hospital discharge. A number of basic achievements during anesthesia and surgery have to be considered to ensure a safe early extubation of the patients followed by monitoring and care in a non-intensive care unit.10 The necessary elements should be focused in a fast track protocol.3 The benefits of those standardized protocols are well confirmed by several studies.4 The implementation of a specialized PACU environment could help to support the fast track protocol and increase its safety.11,12 Conventional aortic valve surgery is being increasingly displaced by a transcatheter approach; although, the short and long-term results of open surgical aortic valve replacement are remarkably good. Surgeons must reduce invasiveness and peri-procedural complications in aortic valve surgery if they want to stay in the arena. This is possible. A less-invasive approach to the aorta employing a partial upper sternotomy is already standardized but, unfortunately, not entirely adapted in all surgical programs.13 Even less widespread are approaches that entirely avoid any sternotomy. To be honest, access through the third intercostal or supra jugular approach is less standardized and still not reliable for any patient.14 But surgeons and the industry need to combine their ideas and collaborate to further advance these techniques. The good news is that valve prosthesis technology has made big improvement by developing sutureless and ‘rapid deployment’ valves that facilitate the implantation through a limited access. These valves are ideal under several aspects: The placement or relief of the valve needs less space. Suturing is not necessary or easily accessible, the implantation is time-saving, and the long-term durability of these valves has been reliably proved. The treatment of aortic valve replacement is a subject of major change. The open surgical valve replacement will still have a role, since many valves, in particular those in younger patients, are not eligible for a TAVI procedure due to the anatomy and calcium burden. However, surgeons need to change their aims. Minimally invasive approaches combined with a nearly zero mortality/complication rate are necessary to stay in the field. Early extubation, bypassing the ICU, and early hospital discharge is feasible for the majority of aortic valve patients. Anaesthesiologist and cardiac surgeons have to work closely together to achieve this goal. This supplement aims to bring Anaesthesiologist and surgeons together. The basic principles and techniques and the environmental needs will be discussed in this issue. Davy Cheng from London, Ontario will present the current evidence on fast track patient management. Marcus Lancé from Maastricht will discuss patient selection and optimization. Marco Ranucci from Milan will present anaesthesiological aspects of fast track in cardiac surgery. Jörg Ender from Leipzig will focus on post-operative patient care and hospital implication of a fast track program. All authors hope that this supplement will stimulate and guide the implementation of fast track programs for Aortic Valve Replacement Surgery.