Fast-track extubation guided by pulmonary artery pressure monitoring after ventricular septal defect closure in infants with pulmonary hypertension

Background: The fast-track extubation approach in pediatric cardiac surgery shortens hospital stays and reduces medical costs. Objectives: This study aims to evaluate the feasibility of the fast-track extubation approach and the role of intraoperative pulmonary artery pressure (PAP) monitoring in managing patients with preoperative pulmonary hypertension (PH) who underwent ventricular septal defect (VSD) closure. Methods: This retrospective study included 102 infants with VSD and preoperative PH (mean PAP > 20 mmHg on cardiac catheterization). We excluded four cases that required complex procedures with long cardiopulmonary bypass time for associated lesions. Intraoperative systolic PAP monitoring was performed to evaluate the suitability of the fast-track extubation approach (<35 mmHg). We defined the fast-track extubation approach as extubation in the operation room after VSD closure. This study also aimed to assess the predictors of postoperative adverse events. Postoperative adverse events included in-hospital death, PH crisis and prolonged mechanical ventilation time, and nitric oxide (NO) administration. Results: The fast-track extubation approach was carried out in 39 patients (38 %). One in-hospital death (1 %) occurred in a non-fast-track patient due to postoperative PH crisis. Two patients (5.1 %) required re-intubation after the fast-track extubation approach due to upper airway issues. The frequency of NO inhalation and administration of pulmonary hypertensive medicines was significantly lower in the fast-track group than in the non-fast-track group (P < 0.001). Multivariate analysis revealed that body weight of <4 kg at surgery (P = 0.006), surgery by trainees (P = 0.003), and greater intraoperative systolic PAP (P < 0.001) were significant risk factors for postoperative adverse events. Conclusions: Our findings showed that the fast-track extubation approach after VSD closure in infants with preoperative PH was feasible, as indicated by the low frequency of re-intubation and postoperative adverse events. Intraoperative systolic PAP measurement was useful for selecting patients to be included in the fast-track extubation approach.