Fast track minimally invasive aortic valve surgery: patient selection and optimizing

Fast track cardiac surgery started in the late 1980s due to a rapid growing amount of operations putting a high pressure on resources, particularly on intensive care capacity. The early fast track studies showed that this technique is feasible and safe for selected patients and procedures. Although some limitations of fast tracking such as patient age, co-morbidities and prolonged operation time were later described, this did not stop further extension of patient and procedure selection criteria. Nowadays, fast track pathways are used to improve patient care as a shorter ICU stay seems to decrease mortality. These pathways are applicable to various surgeries, including aortic valve procedures and combined surgery, because of the development of surgical and bypass techniques which allow less invasive anaesthesia or even conscious sedation. In principle, every patient could be treated as a fast track patient if preparation of the patient and scheduling of the operations are considered. Several strategies could optimise the physiological condition of patients and broaden the patient selection criteria. Avoidance of perioperative anaemia might be as important as keeping the haemodynamic condition stable to achieve optimal organ protection. Current selection criteria should be based on surgical parameters and augmented with the patient s frailty and performance status. All of them should be continuously adjusted during the process. However, most important is a concerted team approach with all contributors having the same mindset.