Establishment of an Enhanced Recovery after Surgery Protocol for Cardiac Transplant Surgery (ERACTxS)

All articles of this category (opens in new window) Background E nhanced R ecovery A fter S urgery (ERAS) protocols gained increasing importance in recent years to improve clinical outcomes in patients undergoing general cardiac surgeries. Implementing ERAS protocols for cardiac transplant surgery (ERACTxS) can further aim to promote early postoperative recovery even in high-risk and multimorbid patients undergoing orthotopic heart transplantation (OHT). Methods: We retrospectively reviewed data of all consecutive adult patients who underwent OHT at our center between 2017 and 2022. In 2020, we implemented an ERACTxS protocol for cardiac transplant surgery, including “ERACTxS bundles” for prehabilitation, goal-directed perfusion, fast-track surgery anesthesia, and rehabilitation. Baselines, perioperative parameters, complications, and early clinical outcome were compared between two groups, dividing patients into an ERACTxS group after implementation of the protocol and a pre-ERACTxS group before the implementation of the protocol. Results: A total of 102 patients were included in the study, with 53 patients (52%) in the ERACTxS group and 49 patients (38%) in the pre-ERACTxS group. The median age was 50 ± 12 (vs. 51 ± 11) years, and 74% (vs. 63%) were male. Baseline characteristics were similar in both groups. Within the ERACTxS group, the extracorporeal circulation time was 189 ± 43 minutes vs. 218 ± 62 minutes ( p = 0.007) with a reperfusion time of 77 ± 26 minutes vs. 98 ± 22 minutes ( p = 0.003), respectively. There was no significant difference regarding warm and cold ischemic times. ERACTxS patients showed a lower rate of renal replacement therapy with 47.2% vs. 71.4% ( p = 0.031) and a trend toward shorter ventilation time with 40 ± 100 minutes vs. 67 ± 164 minutes ( p = 0.09). The incidence of severe primary graft dysfunction necessitating mechanical circulatory support was 7.5% in the ERACTxS group vs. 18.4% in the pre-ERACTxS group ( p = 0.09). There was no significant difference regarding short-term survival with 96% in both groups and 1-year survival with 88.7% in ERACTxS patients and 91.8% in pre-ERACTxS patients. Conclusion: ERACTxS protocols include bundling of pre-, peri-, and postoperative management and treatments. Since the implementation of ERACTxS, patients undergoing OHT showed a trend toward a lower occurrence of primary graft dysfunction, shorter ventilation times, and a lower rate of renal replacement therapy. Overall, the establishment of an ERACTxS protocol in high-risk patients undergoing OHT is a feasible and safe strategy. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany