Perioperative Factors Associated with Delayed Extubation After the Ross Procedure for Aortic Regurgitation: A Retrospective Cohort Study

Delayed extubation after cardiac surgery can prolong intensive care unit (ICU) stay and increase resource use. We retrospectively studied 78 pediatric and young adult patients who underwent the Ross procedure for aortic regurgitation at Shanghai Children's Medical Center from January 2017 through November 2025. Delayed extubation was defined as successful tracheal extubation more than 48 h after completion of the index operation. Candidate factors were evaluated with univariate analyses; least absolute shrinkage and selection operator (LASSO) logistic regression was used as an auxiliary reduction method, and final multivariable estimates were obtained with Firth-penalized logistic regression. Internal validation was conditional on the fixed final model and used 1000 bootstrap resamples. Delayed extubation occurred in 22 patients (28.2%). Higher preoperative left ventricular ejection fraction (OR 0.64 per 5% increase, 95% CI 0.43-0.92) and hemoglobin (OR 0.65 per 10 g/L increase, 95% CI 0.42-0.95) were associated with lower odds, whereas longer cardiopulmonary bypass time was associated with higher odds (OR 1.09 per 10-min increase, 95% CI 1.02-1.17). Modified blood St. Thomas cardioplegia had a lower but non-significant adjusted odds estimate than histidine-tryptophan-ketoglutarate cardioplegia and is vulnerable to confounding by indication. The exploratory model had an apparent AUC of 0.838 and an optimism-corrected C-index of 0.799. With only 22 events, model-selection uncertainty, and no external validation, these findings are hypothesis-generating and do not define a bedside decision rule.