Feasibility and Safety of Operating Room Extubation After Minimally Invasive Cardiac Valve Surgery: A Systematic Review and Meta-Analysis

Background: Minimally invasive cardiac valve surgery has emerged as a preferred approach in selected patients, yet optimal postoperative extubation timing remains debated. This systematic review and meta-analysis examined clinical outcomes associated with extubation in the operating room (OR) versus the intensive care unit (ICU) among adult patients undergoing minimally invasive cardiac valve surgery. Methods: The study was conducted according to PRISMA guidelines. A single unit of analysis was applied throughout. Pooled odds ratios were computed with the Mantel–Haenszel random-effects method; where a study reported only a matched or covariate-adjusted estimate, that estimate was reserved for a prespecified sensitivity analysis using the generic inverse-variance method. Results: Five observational studies (2023–2025) including 1101 OR-extubated and 899 ICU-extubated patients from high-volume centers with fast-track or enhanced recovery pathways were included. OR extubation was associated with lower odds of reintubation (OR 0.40; 95% CI 0.24–0.69; I2 = 0%), postoperative delirium (OR 0.47; 95% CI 0.31–0.72; I2 = 0%), and pneumonia (OR 0.30; 95% CI 0.16–0.53; I2 = 0%). No significant differences were observed for new-onset atrial fibrillation, stroke, or reoperation for bleeding. Thirty-day mortality was reported by four of the five studies and comprised few events (5 of 1043 ORE versus 17 of 645 ICE across the four studies reporting this outcome); given the small number of events, the concentration of deaths in the higher-risk ICU-extubated patients, and the reliance of the pooled estimate on two confounded cohorts, this difference is not interpretable as a treatment effect, and no pooled odds ratio is reported here. Length of stay was consistently shorter after OR extubation but was not pooled because of extreme heterogeneity (I2 = 96–100%). Sensitivity analyses using adjusted estimates attenuated the associations for reintubation and pneumonia, consistent with substantial confounding by indication. Conclusions: In appropriately selected patients undergoing minimally invasive valve surgery, OR extubation is feasible and is associated with a recovery profile at least comparable to that of ICU extubation. Because extubation location was determined largely by intraoperative and early postoperative stability, these associations should be read as reflecting patient selection rather than a causal benefit of the strategy. The findings support the feasibility of OR extubation in appropriately selected patients at experienced centers and motivate prospective, ideally randomized, evaluation.