Early extubation is one of the key components of ERAS (Enhanced Recovery After Surgery) pathways in cardiac surgery. On-table extubation (OTE) has been shown to be feasible in appropriately selected candidates undergoing off-pump coronary artery bypass grafting since the early 2000s. However, its feasibility and potential benefits in patients undergoing cardiac procedures requiring cardiopulmonary bypass remain a matter of debate.
This single-center, retrospective observational cohort study aimed to determine whether extubation timing affects clinical outcomes and resource utilization in patients undergoing different types of cardiac surgery at a high-volume center.
To provide further evidence in this setting, Tobia et al. report a single-center retrospective cohort study identifying patient- and procedure-related factors associated with intraoperative eligibility for OTE (n = 1026) compared with early extubation (EE), defined as extubation within the first 6 hours in the intensive care unit (ICU) (n = 988). The authors also compared clinical outcomes between both groups.
No significant differences were observed in reintubation, ICU readmission, or 30-day mortality. However, OTE was associated with a significant reduction in costs ($3029 per patient) and a shorter hospital length of stay (0.78 days) compared with EE.
All included patients were adults (>18 years). Most patients (1447) underwent isolated coronary artery bypass grafting (CABG). The remaining procedures included aortic valve replacement (n = 179), mitral valve repair (n = 135), mitral valve replacement (n = 97), and combined procedures (CABG and valve surgery), including cases of endocarditis and valve surgery associated with aortic root or arch procedures. Patients undergoing isolated aortic root or arch surgery were excluded.
Importantly, patients selected for OTE had significantly fewer comorbidities than those undergoing EE, including a lower prevalence of smoking, chronic lung disease, hypertension, cerebrovascular disease, diabetes mellitus, and end-stage renal disease. They also had a lower body mass index and a higher left ventricular ejection fraction.
In the perioperative setting, patients in the OTE group required fewer blood products and had shorter cross-clamp and cardiopulmonary bypass times.
Conversely, patients selected for EE were more often urgent or emergent cases, or underwent more complex procedures, such as combined CABG and valve surgery. They also had a higher prevalence of NYHA class III/IV heart failure and higher STS scores.
Overall, the authors conclude that on-table extubation is a safe and effective strategy in appropriately selected patients undergoing cardiac surgery. Their findings support the use of OTE in experienced centers with established protocols, while emphasizing the need for additional prospective studies to confirm these results and define optimal selection criteria.
COMMENTARY:
In light of these findings, it is important to place the results within the context of the current evidence. The cost savings and shorter hospital stay associated with OTE provide a particularly relevant perspective for perioperative management in cardiac surgery. Nevertheless, these findings should be interpreted with caution.
The available evidence, including recent meta-analyses and large multicenter studies, suggests that the decision to perform OTE should be individualized. Its safety and effectiveness depend largely on appropriate patient selection and on the specific experience of the center.
The differences in baseline comorbidities between the study groups highlight a persistent selection bias in the OTE literature. Large national studies reinforce this pattern: patients undergoing OTE tend to be younger, have fewer comorbidities, better ventricular function, lower surgical risk, and are more frequently treated with less complex and elective procedures.
This same pattern is also reflected in perioperative characteristics. Patients in the OTE group had significantly shorter cross-clamp and cardiopulmonary bypass times and were less likely to receive intraoperative blood products.
In this context, one relevant limitation of the study is the absence of a detailed analysis of vasoactive drug use during the perioperative period. Extubation increases oxygen consumption and cardiac stress. This effect is usually well tolerated in patients with preserved cardiac function, but it may become problematic in those requiring substantial hemodynamic support. Therefore, the need for and intensity of vasoactive support during and at the end of surgery are key factors that probably influence suitability for OTE and its outcomes.
In a recent meta-analysis by Naito and Takagi, OTE appeared to be associated with lower rates of stroke and short-term mortality in unadjusted analyses. However, after propensity score adjustment, these differences were no longer significant, suggesting that the observed benefits mainly reflect patient selection rather than the intervention itself.
Indeed, when OTE is applied to less selected cohorts, as in the multicenter study by Etchill et al. (2024), it has been associated with higher in-hospital mortality, higher reintubation rates, and a greater incidence of postoperative pneumonia. Mortality was also significantly higher in centers with low OTE utilization (<10%).
These data suggest that there is an optimal patient profile for on-table extubation. Its use is highly dependent on procedural complexity and intraoperative course, making continuous and rigorous patient assessment essential before and during surgery.
Another decisive factor is center experience. In the study by Tobia et al., the OTE rate was 50.9%, far higher than that reported in most hospitals. In multicenter analyses, many centers either do not perform OTE or use it in only a very small proportion of patients.
The relevance of institutional experience becomes clear when outcomes are analyzed according to volume. In low-experience centers, OTE is associated with higher in-hospital mortality compared with EE. In contrast, in high-volume centers, mortality is comparable between both strategies. This suggests a clear volume–outcome relationship, reflecting the need for experience, multidisciplinary coordination, and consolidated protocols.
From an economic perspective, the approximate saving of $3000 per patient may be limited if OTE is restricted to low-risk patients, in whom the incremental benefit is smaller. Conversely, if OTE is extended to higher-risk patients and leads to more complications, overall costs could increase. Therefore, the real economic impact probably also depends on institutional factors such as OR efficiency, staffing models, and ICU turnover capacity.
Taken together, the available evidence suggests that on-table extubation should not be regarded as a universal strategy, but rather as a potentially beneficial tool when applied to the right patient, in the right setting, and by experienced teams.
Moreover, successful implementation of OTE in our environment would require organizational and cultural changes at several levels: cardiac surgery, including optimization of hemostasis; anesthesia, including the selection of analgesic and sedative drugs and management of vasoactive support; and intensive care, including acute management of the extubated postoperative patient. This requires the development of specific multidisciplinary protocols and a change in approach, recognizing that the decision to perform OTE is dynamic and must be continuously reassessed throughout the procedure.
As current studies point out, future research should focus on defining patient selection criteria, establishing minimum institutional requirements, and developing standardized protocols that allow safe and efficient implementation of OTE in cardiac surgery.
REFERENCE:
Tobia J, Pepe R, Soliman F, Yang N, Laplaca T, Telenson S et al. On-Table Extubation following Cardiac Surgery: Clinical Outcomes and Associated Cost Reductions from a Single Academic Medical Center. J Cardiothorac Vasc Anesth. 2026 Feb;40(2):467-477. doi: 10.1053/j.jvca.2025.10.014.
