“Enhanced Recovery After Surgery” Pathway Promising for Cardiac Surgery

Male patient lying in hospital bed recovering from surgery

Over the past decade, various non-cardiac surgical specialties have created perioperative guidelines aimed at enhanced recovery after surgery (ERAS). These pathways have been tied to significant improvement in clinical outcomes, shorter length of stay and lower costs.

In 2018, a multidisciplinary team at Brigham and Women’s Hospital led by Tsuyoshi Kaneko, MD, director of Clinical Outcomes Research at the Brigham, an assistant professor of Surgery at Harvard Medical School, and the senior principal investigator, developed a multimodal ERAS program to optimize perioperative care in cardiac surgery. The team also included Sary Aranki, MD, an associate professor of Surgery, and two co-first authors, Farhang Yazdchi, MD, and Sameer Hirji, MD, who are both cardiothoracic surgery fellows in the Division of Thoracic and Cardiac Surgery. Together, their study reports promising early results in Seminars in Thoracic and Cardiovascular Surgery.


The researchers began by assembling two cohorts:

  • ERAS cohort—102 patients who underwent cardiac surgery under the ERAS quality improvement initiative protocol between May 2018 and June 30, 2019 (not all patients undergoing cardiac surgery during this period were eligible for the ERAS pathway)
  • Pre-ERAS cohort—1,195 cardiac surgery patients treated by the same surgeons and clinicians between January 2017 and March 2018 (certain exclusion criteria applied to this group as well)

The analysis included 75 matched pairs of patients from the two groups.

Primary Outcomes

Compared with the pre-ERAS group, the ERAS cohort had significantly better primary outcomes (values listed are medians):

  • Ventilation time—3.5 vs. 5.3 hours (P=0.01)
  • ICU length of stay—28 vs. 48 hours (P=0.005)
  • Postoperative hospital length of stay—5 vs. 6 days (P=0.03)

Secondary Outcomes

There were no deaths within 30 days. The two groups did not differ with regard to:

  • 30-day readmission rate
  • Postoperative stroke
  • Postoperative acute kidney injury
  • New atrial fibrillation
  • Reoperation for bleeding
  • 2-year survival

Launching an ERAS Protocol

The authors provide detail about the interventions included in the ERAS pathway in each phase of surgery (pre-, peri- and postoperative). They also discuss how they overcame system-level barriers at the hospital and “learning inertia” among the staff.

Since the time the Brigham pathway was created, the new ERAS Cardiac Society has published evidence-driven, expert-consensus recommendations in JAMA Surgery to help institutions develop their own ERAS algorithms.

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