Ultra-Fast-Track Extubation Within Four Hours Versus Conventional Ventilation After Robotic Coronary Artery Bypass Grafting: A Systematic Review of Intensive Care Unit Stay and Postoperative Atrial Fibrillation Outcomes

Robotic-assisted coronary artery bypass grafting (RA-CABG) is a minimally invasive procedure that can lead to quicker recovery. Ultra-fast-track extubation (UFTE) within four hours post-surgery is a key element of enhanced recovery. This review compared UFTE versus conventional ventilation (>4 hours) on intensive care unit (ICU) stay and postoperative atrial fibrillation (POAF) in adults undergoing RA-CABG. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, databases (MEDLINE, Embase, Cochrane Central, and others) were searched until July 2025. Inclusion criteria targeted adults undergoing RA-CABG, with outcomes assessed by ICU length of stay (LOS) and POAF incidence. The risk of bias was assessed using the Cochrane Risk of Bias 2 (ROB 2) tool for randomized controlled trials (RCTs) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies. Nine studies (one RCT and eight retrospective cohorts; total n=3,223) were included. UFTE reduced ICU LOS (e.g., median 21 vs. 45 hours; p=0.001) and hospital LOS (1-4 days shorter). POAF rates were similar or lower with UFTE (e.g., 3.2% vs. 14%; p=0.004). No increases in mortality, re-intubation, or other complications occurred. UFTE after RA-CABG safely shortened ICU and hospital stays without elevating POAF or adverse outcomes. These findings support the use of UFTE in enhanced recovery protocols for carefully selected patients. However, the observational nature of most evidence highlights the need for more high-quality RCTs to confirm benefits.