Technological advances to enhance recovery after cardiac surgery
Review Article

Technological advances to enhance recovery after cardiac surgery

Kevin W. Lobdell1, Jehangir J. Appoo2, Geoffrey A. Rose1, Brian Ferguson3, Subhasis Chatterjee4,5,6

1Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA; 2Libin Cardiovascular Institute, University of Calgary, Calgary, ALB, Canada; 3Arena Labs, Westlake, OH, USA; 4Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; 5Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA; 6CHI St Luke’s Health - Baylor St Luke’s Medical Center; Houston, TX, USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Kevin W. Lobdell, MD. Atrium Health, PO Box 32861, Charlotte NC 28232, USA. Email:

Abstract: Surgery, and especially cardiac surgery, is common, costly, and entails considerable risk. Significant progress has been made in recent years to improve quality, promote patient safety, and increase value and cost-effectiveness in surgical care. Enhanced Recovery After Surgery (ERAS) initiatives are increasing in popularity, improving outcomes, and enriching patient satisfaction. First developed for abdominal surgical cases, ERAS has increasingly established itself across all surgical subspecialities, including cardiac surgery. ERAS focuses on evidence-based initiatives in the preoperative, intraoperative, and postoperative phases of care to promote patient well-being and efficient care. The deliberate, judicious incorporation of technology into surgery and the periprocedural home has tremendous, revolutionary potential in all phases of care and is consistent with ERAS principles. This technology can be harnessed by physicians and the care provider team, the healthcare system, and perhaps most importantly, by patients themselves to lead to a higher level of engagement. We will explore technology’s transformational capability by concentrating on cardiac surgery because of its prevalence, costs, risks, and contribution to the healthcare system’s bottom line. In addition, the role that ERAS combined with technology can play in a constructive manner will be important. We discuss the disruptive effect that the COVID-19 pandemic offers to accelerate these developments. While the human cost of the pandemic has been staggering, in the post-COVID world, the lessons learned can be vital. Finally, we seek to show that the opportunities technology provides are closely related to what both patients and the physician and provider teams want. As technology inevitably becomes more integrated into healthcare, the ability to harness technology to maximize patient outcomes and well-being while promoting more efficient healthcare delivery will be critical.

Keywords: Enhanced recovery; cardiac surgery; technology

Received: 07 August 2020; Accepted: 15 January 2021; Published: 25 September 2021.

doi: 10.21037/jhmhp-20-114


Health care is expensive. In 2017, the global burden of disease (GBD) was estimated to be $7.8 trillion (in US dollars), or about 10% of the total global gross domestic product, which translates into approximately $1,080 per capita for the world’s population. In the United States, comparable numbers for health care costs are 19% of US gross national product and $10,586 per capita (1,2). Moreover, this share of the GNP will continue to rise in the foreseeable future for several reasons, including the aging of the population and the advent of complex diagnostic and therapeutic advances. Indeed, in an International Business Machines (IBM) poll in 2012 of 480 economists, health care was determined to be the most inefficient system in the global economy, with waste estimated to be $2.5 to 4 trillion annually (3). This healthcare inefficiency in the United States is complex and has been characterized by three types of waste: administrative waste at the national level (Medicare, private insurance), the level of which far exceeds that in comparable European and North American countries; significant operational waste (inefficient and unnecessary use of resources at the healthcare system/hospital level); and clinical waste (services that provide marginal or no health benefit at the individual patient level) (4). Given that productivity in health care lags behind that in other industries, such as information technology (IT), finance, insurance, real estate, and retail (5), a tremendous number of opportunities exist for improving healthcare, an industry with ever-diminishing profit margins in many of its sectors.

When the focus is narrowed to the global burden of surgery (GBS), estimates suggest that 11% to 28% of the GBD is attributable to the GBS. The associated worldwide surgical procedural volume is estimated to be 234 million operations annually, with an overall surgical mortality of approximately 0.4% and morbidity estimates ranging from 3% to 17% (6-14). Surgical complications correlate with additional costs and diminished life expectancy. Results of the American College of Surgeons’ National Surgical Quality Improvement Program analysis indicated that any one of 22 distinct complications that developed in the first 30 days postoperatively reduced patients’ median life expectancy by an average of 69% (range 44–77%) (15). Thus, the imperative to reduce the incidence of perioperative complications is clear.

When the focus is even further narrowed to acquired heart disease, we can see the widespread prevalence of its impact. Acquired heart disease affects 30.3 million adults (12.1% of the US adult population) (16), and the Society of Thoracic Surgeons’ Adult Cardiac Database indicates that approximately 295,000 cardiac surgical operations are performed annually, with a mortality rate ranging from 1 to 10%, depending on the procedure (17). The incidence of complications associated with cardiac surgery ranges from 33% to 54% for all complications and from 11% to 17% for major complications (which include stroke, reoperation, prolonged ventilation, deep sternal wound infection, and acute renal failure; minor complications include atrial fibrillation (AF), pleural effusion, pneumonia, and deep venous thrombosis). These complications reduce life expectancy, increase patient and family dissatisfaction, have adverse implications for hospital-based quality metrics, and increase health care costs (18).

Capital expenditures on health IT continue to increase, to a projected $6.4 billion in 2021, a nearly 7% increase over the last five years (19). Although the optimal threshold remains unknown, this proportion will inevitably continue to increase steadily. That said, it is noteworthy that digital health venture capital increased nearly 10-fold from 2010 to 2017; more than $40 billion was invested in digital health in the 2010s, reflecting the robust promise in this arena (20).

The burgeoning field of digital health care (21) includes telemedicine, the Internet of Medical Things (IoMT), remote patient monitoring devices, patient engagement and empowerment tools, software as medical device, advanced analytics, artificial intelligence (AI), cloud-based storage platforms, cybersecurity, wireless medical devices, mobile medical applications for smart phones, and novel digital devices (22,23). Indeed, this field has advanced so rapidly that technologies that were inconceivable to healthcare practitioners a decade ago will become routinely used in the next 5–10 years.

Enhanced recovery

To confront the healthcare challenges facing the country, the Institute for Healthcare Improvement (IHI) has developed the “Quadruple Aim” of population health: better outcomes, improved patient experience, improved clinician experience, and reduced costs to improve the value of health care (24). Achieving these goals is central to the Enhanced Recovery After Surgery (ERAS) movement. This initiative has worked toward improving the quality and value of surgical care by combining multimodal strategies that mitigate the stress response to reduce postoperative pain without opioids, overcome postoperative ileus, and reduce intravascular volume shifts while preserving and enhancing physiologic reserve (25-28). The invasiveness and duration of cardiac surgery and cardiopulmonary bypass amplify the routine physiologic stressors of surgery by causing more profound metabolic, inflammatory, and immunologic derangements (29,30). The ERAS efforts focus on the critical members of the perioperative care team: surgeon, anesthesiologist, intensivist, nurse, perfusionist, physical therapist, pharmacist, and nutritionist, among others. Furthermore, these perioperative care efforts highlight the British cycling coach Sir David Brailsford’s concept of the “aggregation of marginal gains” whereby small, incremental gains across a broad platform of processes can cumulatively achieve meaningful benefits and improved outcomes (31).

Ultimately, the benefit of any technological advance is determined by whether it serves the needs of patients and their physicians and care teams. An insightful survey from the James Lind Alliance Priority Setting Partnership in adult heart surgery (32) addresses this question. This survey of 629 heart surgery patients, caregivers, and health care professionals aimed to identify their biggest priorities with respect to cardiac surgery. While patients and providers had slightly different highest priorities, the most common questions focused on basic information (improving outcomes in patients with comorbidities, when heart valve intervention should occur in asymptomatic patients, minimally invasive vs. open heart surgery), quality of life (expected course after heart surgery, frailty and heart surgery, the value of prehabilitation), and the risks and management of postoperative complications (minimizing damage to other organ system and reducing postoperative AF or wound infections). This information about patients’ priorities helps clinicians recognize that they and their patients do not necessarily have the same focus when it comes to surgery. The ultimate embrace of the technological advances will rest on how well these priorities are addressed for all involved; indeed, patient empowerment and shared clinical decision-making are increasingly recognized as the major determinants of value (33).

In addition to meeting patient and provider expectations, technology that transforms health care will also need to meet the Quadruple Aim, bend the cost curve down, and promote real growth in productivity to benefit the healthcare system. Specifically, technology can aggregate and integrate volumes of clinical, care process, and financial data that can be rapidly analyzed to provide insight and improve care. Care variation, responsible for many disparate outcomes in health care, can be reduced, and outcomes can be reliably improved. Technology also bolsters risk assessment and decision support. Similarly, technology can reduce friction between employees by enhancing interoperability, workflow, and ease of use. The opportunity to identify premium talent can be leveraged with technology by evaluating adherence to standards of care and recognizing superior outcomes.

Solutions and technologies

The world has been rapidly transformed by computing and the internet into a less centralized network of people and technology (34,35). These developments have been outlined by Peter Diamandis and Steven Kotler and classified into the “Six Ds” of exponential technologies: Digital information tools that Deceptively increase in scope and utilization to Disrupt, Demonetize, Dematerialize, and Democratize information while accelerating the ongoing transformation (36). All of these principles conform to the ERAS goals of empowering the patient and healthcare team by creating a more streamlined, evidence-based care pathway that is followed both in the hospital immediately after surgery and at home during recovery.

Data as a platform

Data as a platform (DAAP), which fuses the technology ecosystem and satisfies the specific needs of different users, is foundational to enhancing and transforming surgical care (37). The growth of health data is staggering, with 153 exabytes (i.e., one quintillion bytes) produced in 2013 and as many as 2,314 exabytes forecasted for 2020 (48% annual increase) (38). Strategic imperatives for DAAP include scalability, rapid onboarding of novel data sources, and support of all types of data and analytics. The potential benefits will include improved personalization, access, prediction, health, and quality and cost of care (39,40). However, issues regarding governance, security, and privacy are important and will require thoughtful consideration from all stakeholders in the health care enterprise.

Wearables and the Internet of Medical Things

Approximately 80% of patients have smartphones, and 90% have some type of mobile phone. Additionally, 17% to 29% of patients check their smart device 50 or more times a day. The average person uses their phone 2.5 hours daily, and more than one-third of people look at their smartphone within 5 minutes of waking up (41-43). Wearables, such as smartwatches and fitness bands, are used by 5% to 11% of the world’s adult population (42). The complementary and unique digital connection to patients provides an opportunity to improve quality and value as components of the IoMT, where—this year—an estimated 28 billion discrete data elements will be connected (44). This incredible penetration of technology provides a rich infrastructure that can be easily incorporated into the health care ecosystem, where the prospects of ERAS can be transformational. By providing patients with wearable technology, a unique level of patient engagement can be harnessed for earlier identification of potential problems and deviations from the expected postoperative course.

The average age of adult cardiac surgery patients is greater than 60 years. In this patient population, attention is required to address technical challenges with setup and use due to impaired “mobility, vision, memory, and hearing, plus, all too frequently, social isolation, loneliness, and depression” (45). It is important to remember that, for some older individuals, there is a valuable aspect of social interaction with the health care system that technologic solutions will supplant. The process of engaging patients via remote monitoring is important and involves building rapport, sharing information, and providing guidance (46). Our patient rate of compliance in this population is favorable (>90%) and exceeds the rates documented by others (47,48). As Krishnaswami and colleagues (49) highlight, the key to gerotechnology as it addresses cardiovascular care is to improve patient-centered care, lower treatment-related risk, improve quality of life, and alleviate symptoms. This involves identifying the goals of care, assessing the barriers to the digital use of health, optimizing the match between patient and technology, providing adequate support to the participant and caregiver, and continually reassessing the impact of these technologies and optimizing the process further. Improving the engagement of older patients can have positive effects and may reduce readmissions if potential complications are recognized early on, with clear financial benefits to the healthcare system.

One opportunity that wearable technology provides is in optimizing care for AF. AF is a common cardiac arrythmia and is associated with increased risk of morbidity from stroke, mortality, and healthcare expenditures. Its prevalence is estimated at almost 1% of the general population and 10% of people aged 65 years or older, with a sizable portion of cases (13%) being undiagnosed (50). The Stanford University Apple Heart Study is the archetype for using wearable technology (Apple Watch) for pragmatic, large-scale studies of prevalent and vexing health care problems such as AF (51-53). Of the 400,000 participants recruited, 2,161 (0.52%) received an irregular pulse notification on their smart phone. One-third of these participants were found to have AF, which allowed early diagnosis and management of this condition.

Intelligent computing

AI was pioneered by Alan Turing (54), as well as by John McCarthy and his colleagues at Dartmouth College (55). AI can be defined as “the branch of computer science dealing with the simulation of intelligent behavior in computers” (56) and includes sensing, engaging, reasoning or decision making, and learning (57). AI maintains great promise in prescriptive (what we should do) health care computing efforts and will complement descriptive (what happened) and proscriptive (what could happen) computing.

The process of producing AI algorithms is complex, requiring experts, computing power, and large volumes of robust data structured in an organized fashion. AI algorithms can be static (unchanged over time) or dynamic, whereby data and outcomes create a virtuous cycle by continuing to inform and update the algorithms (58,59). This dynamic process and its potential are fueling rapid growth in health care AI; future investment in this area is projected to be $6.6 billion in 2021 and $36 billion by 2025 (with a compound annual growth rate of 40% to 45%) (60,61). According to Accenture, “when combined, key clinical health AI applications can potentially create $150 billion in annual savings for the US health care economy by 2026” (62). The US Food and Drug Administration (FDA) has provided guidance on AI algorithm development but, to date, does not have a standardized validation process (63,64).

Similar to linear regression risk models, the quality of algorithms can be measured according to discrimination and calibration, as well as precision, recall, and accuracy (65). The risks of AI include, but are not limited to, bias and diminution of clinician decision making (66).

Various classifications are used to categorize and characterize AI. Familiar types of AI used in health care include machine learning, whereby computers learn, improve, make predictions, and process and analyze language (i.e., natural language processing) (67,68). The use of AI in cardiac care includes risk modeling (preoperative and postoperative), imaging, and natural language processing for electronic medical records (69). The potential of AI to further develop ERAS concepts may help to refine future iterations of ERAS guidelines. Moreover, in the operational framework outlined by Bentley and colleagues (4), the concept of clinical waste and reducing services that provide little or no benefit to the patient can be reduced once meaningful data are harvested and analyzed, and care pathways and protocols can be developed and implemented.

Complex modeling

Complex modeling, in which computers simulate complex systems with a combination of mathematics and physics, has been used effectively in weather and aviation simulations and is now increasingly used in biologic systems (70). For example, complex modeling is being used to evaluate anatomic, physiologic, and pathophysiologic phenomena and shows great promise in predictably improving the care of cardiovascular patients (71). Valuable examples of this technology include characterizing relationships of ventricular volume, wall stress, and stroke volume associated with surgical ventricular reconstructive procedures or other intracardiac devices (72,73).

Virtual assistants

Virtual assistants can help with routine tasks such as compliance with therapeutic regimens, engagement and behavior modification, and schedule management and reminders (74,75). There is considerable optimism that virtual assistants, integrated with novel tools and evolving processes, can improve access to care, coordination of care, efficiency, engagement, and, ultimately, outcomes (75). The ability to harness virtual assistants for patient care can ensure that patients continue following the expected recovery course, consistent with ERAS goals.

Additive manufacturing

Additive manufacturing, also known as 3D printing (3DP), uses computer-aided design or a scanner for input and a printer that adds material layer by layer to create an object (76). Charles Hull created the first machine part with 3DP in 1983, and the process is now used to provide parts in aerospace and automobile industries with an “on demand” capability to increase efficiency (77). For health care, data acquisition in the 3DP process can be done by using computerized axial tomography, magnetic resonance, and echocardiography to facilitate rapid prototyping for product development, custom implants, anatomic models, and virtual surgical planning, among others (78). Customized transcatheter replacement valves and endovascular aortic stent grafts are notable examples of 3DP products used to treat cardiovascular disease (78).


Augmented reality (AR) has been used to remotely match rare, experienced talent with uncommon problems in other fields, such as automobile repair (79). One can easily extrapolate and realize AR’s potential in educating surgeons and performing technically challenging or high-risk surgical procedures (80-82). As we integrate advanced imaging and minimally invasive approaches, the potential usefulness of AR and virtual reality (VR) is advancing significantly and synergistically (83,84). Over time, this can lead to the development of better simulation exercises to train the entire perioperative care team to anticipate and react various complications in the perioperative period (85). The concept of failure to rescue is an important determinant of variation in mortality after coronary artery bypass grafting (CABG) surgery (86). Namely, the difference among hospitals is not so much the difference in the incidence of major complications such as stroke, renal failure, or prolonged mechanical ventilation; rather, the difference is in how quickly complications are recognized and treated to mitigate their severity.


Telehealth provides patients with remote access to health care via real-time, audiovisual technology. The solutions can be particularly valuable for solving access problems that result from disparities, disabilities, long physical distance from health care centers, and a lack of expertise and specialized personnel, as well as from high-risk situations such as virulent infections and combat. Administrative and clinical data can accrue from telehealth solutions and provide the opportunity to exponentially increase the value of these efforts.

The electronic intensive care unit (eICU) has been in existence for more than 15 years and has shown promise for enhancing the quality and reducing the cost of ICU care while also providing flexibility for clinical teams and scalability to include small ICUs or multiple large ICUs (87-92). In addition to the audiovisual technology utilized in the eICU, large volumes of clinical data can be acquired and analyzed to assist with prioritization, workflow, and decision support (93-95). Similarly, “tele-rounding” has been used for many years to leverage expertise and also to address the challenges of COVID-19 to minimize patients’ and clinicians’ risk of exposure (96,97). This clearly illustrates how technology could meet a specific need created by the COVID-19 pandemic. As social distancing requirements prevented the intensive care unit (ICU) multidisciplinary rounding process from being conducted in its normal fashion, virtual rounding became a necessity to reduce the likelihood of SARS-CoV-2 transmission among members of the healthcare team. These challenges were anticipated by ERAS thought leaders, who offered guidance to navigate cardiac surgery perioperative care in the COVID world (98). Although telemedicine will continue to become more prevalent, it is important to remember that in-person communication among patient, nurse, and physician still has a valuable reassuring and therapeutic role that technology platforms should strive to enhance and not eliminate.


The novel and large volumes of data that provide a rich opportunity to transform health care present a real and growing risk. Cybersecurity risks include the hacking of medical insurance information, office and hospital medical records, and devices, in addition to phishing and geolocation threats (3,99-102). Interestingly, approximately 25% of health care cybersecurity attackers are “insiders,” which is an order of magnitude greater than that seen in financial services, manufacturing, and retail (3). It is estimated that 175 million records have been breached since 2010, with offices and hospitals being the most frequently targeted victims of cybercrime and insurance companies having lost the greatest volume of records (99). Two-factor authentication and other strategies to reduce the vulnerability of medical records are increasingly prevalent and effective; these measures will not only reduce the actual risk of hacking but also preserve the public’s faith in the integrity of the system.

Solutions and technologies by phase of care

Acute care

Preoperative care and prehabilitation

The novel coronavirus (COVID-19) pandemic has accelerated the use of telemedicine and digital health across most subspecialties, including cardiovascular care. The exponential growth of this demand for increased technology requires a “network” solution (i.e., better technological solutions and processes to accelerate information flow, decision making, and the matching of demands with resources) (103). Atrium Health’s Sanger Heart and Vascular Institute in Charlotte, North Carolina rapidly transitioned to approximately 95% virtual visits (>500/day) (104), and McKinsey & Company data show that “consumer adoption has skyrocketed, from 11 percent of US consumers using telehealth in 2019 to 46 percent of consumers now [middle of 2020] using telehealth...and providers have rapidly scaled offerings and are seeing 50 to 175 times” (105). Furthermore, McKinsey & Company asserts that approximately $250 billion in care could be virtualized (105).

The four pillars of remote patient monitoring are (I) engagement via video visits, messaging, pathways, protocols, and patient reported outcomes (PROs); (II) a secure audiovisual interface; (III) biosensors that allow clinicians to acquire data in a way that replaces and supersedes the traditional physical exam; and (IV) data management and analytics that can apply AI, and specifically machine learning, algorithms to large amounts of data generated by sensors (106,107). Each of these technologies will have variable roles and applications for different patient subsets, but the ERAS concepts can be tied into all aspects of remote patient monitoring.

Preoperative, quantified risk assessment should be routinely performed to help patients and clinicians make decisions and plans (and there is strong evidence that greater risk correlates with greater complications and costs) (18,108,109). Technologies such as cardiopulmonary exercise testing and anaerobic threshold quantification (110-112), biomarkers (113-115), and frailty (116,117) could be incorporated into routine risk assessment and guide modifiable risk-mitigation strategies. Evidence-based approaches that promote prehabilitation can contribute meaningfully to optimizing patients for surgery.

The aggregation of novel and large volumes of data fuels AI’s capacity to improve the efficacy and speed of the modeling process for mortality and morbidity (118-120). This platform offers patients and referring clinicians the opportunity for genuine informed consent and realistic, individualized assessments of risk and recovery prospects before surgery. AI has been investigated in various types of testing and imaging. AI has been utilized in electrocardiography for dysrhythmia detection and in chest radiography, with promising results in accuracy and speed of interpretation (121-123). AI also exhibits promise in more advanced imaging such as echocardiography and MRI (124,125).

Of the 25 machine learning algorithms that received FDA approval as of 2019, 13 of them were for medical imaging, mostly cardiovascular and breast imaging (126). Of the 12 non-imaging-related algorithms, three were for detecting AF. FDA approvals will continue to increase as AI algorithms proliferate across all areas of medicine and are validated in different contexts and clinical settings. Recent contributions in cardiovascular surgery are highlighted in a review by Kilic (59) indicating that the role for AI will only continue to increase in scope.

Novel remote monitoring tools in cardiovascular care are currently being used by a few centers in the management of congestive heart failure, dysrhythmia detection, and perioperative care (127,128). Monitoring of vital signs with cloud-based data sharing is provided by a variety of companies, each with different niches (129-134). An important, emerging area is engagement tools and PROs that increase patients’ involvement in their care. Mobile device applications, commonly used in nonmedical settings, are now used to guide patients through their cardiac surgery journey, measure their well-being, and decrease complications (106,107). The next generation of ERAS cardiac guidelines will continue to define the appropriate implementation phase and roles for these technologies.

Operating room

Robotic surgery and telesurgery have the potential to help with surgical education, treating remote patients, risky environments, and ergonomics (135-137). The operational workflow, which allows a day’s worth of operations to be completed efficiently, can also be monitored and improved (138). In the realm of the individual surgeon, surgical coaching with technology offers great promise to improve surgical skills and outcomes (139). This type of coaching is not natural to surgeons in practice, but just as major league baseball players have hitting coaches and watch videotapes of their performance, similar, periodic engagements of surgeons in practice may be an opportunity to enhance life-long learning.

“Hyper-realistic” training modules created to simulate real-world stress and measure the stress response and regulation with VR (ARENAXR) (140) have the power to train surgical teams in pioneering ways that focus beyond technical skill acquisition to include human factors such as stress, decision-time, and 360-degree awareness.

As noted above, wearables for tracking activity, recovery, and sleep are becoming ubiquitous, easy to use, and affordable. By placing sensors on frontline medical teams to track stress and rest, medical leaders—for the first time in history—have the ability to create real-time dashboards on their health and performance and, more importantly, be sophisticated about understanding burnout (141). Most medical practitioners traditionally have been treated in a “one size fits all” manner; perhaps these dashboards will allow more individualization and personalization in several areas. This will become critical as the cardiovascular surgical workforce becomes more diverse. Moreover, healthcare organizations demonstrating concern for the well-being of their workforce will be seen, not simply as a bonus, but as a necessity for the next generation of healthcare workers.

Similar to commercial aircraft black boxes, the operating room can be outfitted for “real-time data capture and deep clinical analysis of operating room activity...and this information provides comprehensive, objective, and clinically relevant insights into the perioperative environment” (142). The potential benefits for quality and safety are manifold (143-145). Technology also exists to mitigate the risk of “never events” such as retained objects (146-148). An important consideration in all of these technologies is who owns the data: hospitals, the individual surgeon, the patient, the third-party payor? What happens if malpractice is alleged or hospital disciplinary actions are invoked and these recordings are used, not as an opportunity for improvement, but as a means for reprimand, censure, or litigation? These issues are not simple and will require thoughtful deliberation and the establishment of boundaries, respecting the privacy of not just the patient but also the healthcare team.

Traditional data sets can be augmented with additional data (such as the number of admissions, the complexity of patients as measured by acuity scores, high patient-to-nurse ratios, and the experience level of staff) to improve risk assessment and mitigation (65,149).

Post-acute care

Continuity, connectivity, and coordination across the continuum are valuable for transforming health care and vital for higher-risk endeavors such as surgery (75). As the archetype for the advanced, cardiac, periprocedural home, Perfect Care remotely monitors cardiac patients with a combination of video visits; messaging that includes images; biometrics via fitness trackers, scales, and sphygmomanometry; and PROs (150). A precision, personalized approach can be tailored to include pulse oximetry, glucometry, and monitoring of anticoagulation (150-152). In the first nine months of Perfect Care at the Sanger Heart and Vascular Institute, the observed median postoperative length of stay was half a day less than the benchmark, and the readmission rate was approximately 60% of the benchmark (KWL, unpublished data, 01 July 2019 –28 February 2020).

Virtual cardiac rehabilitation has improved compliance, reduced readmissions, and reduced associated costs, as well as producing a sustained reduction of cardiovascular risks (e.g., increased exercise capacity and dietary quality, with reductions in cholesterol levels) (153-155). Table 1 lists these technologies and the phases of care that offer the most potential to enhance recovery.

Table 1

Valuable enhanced recovery technologies by designee and phase of care

Variable Patient Clinician Institution
Preoperative Engagement AI-risk assessment AI-risk assessment
Education AI-diagnostics & imaging
Physiologic assessment
Remote patient monitoring
Intraoperative Robotics Device tracking
Hearable coaching
Postoperative Biomarkers Tele-ICU Tele-ICU
Remote patient monitoring Tele-rounding Tele-rounding
AI-risk mitigation AI-risk mitigation
Post-acute care Remote patient monitoring Remote patient monitoring Remote patient monitoring
All Data as platform

AI, artificial intelligence; ICU, intensive care unit.

Summary and future

A more adaptable, higher-quality, safer, and, ultimately, more valuable health care system requires improved efficiency and efficacy in matching demands with resources. Technologies to improve data management and analytics, digital and telehealth tools, simulation, enhanced cybersecurity, and others, combined with ERAS efforts, have tremendous potential to assist in realizing the IHI’s Quadruple Aim. The COVID-19 pandemic may accelerate many of these processes to transform the health care landscape more rapidly than we could have imagined mere months ago.

The near future of enhanced recovery efforts will include aggregating the most valuable technologies, ascertaining interoperability, and seamless workflow, as well as engagement, learning, and optimization from both patient and clinician perspectives. It will be important to rigorously scrutinize the actual data and the outcomes of its use. Technological advances are not intrinsically valuable in and of themselves; ultimately, they must translate into actual benefits for patients, health care providers, and health care systems.

The future will also include advancement of knowledge about engagement, improved education and implementation, and mitigating the risk of clinician burnout. Technological advancements will be made in intelligent computing, novel biosensors, faster networks, and the incorporation of genomics, proteomics, and other biotechnologies, as well as quantum computing. The role of technology and enhanced recovery efforts will be a catalyst for optimizing patient outcomes after cardiac surgery.


The authors thank the Texas Heart Institute’s Scientific Publications Department for providing editorial support and Katherine A. Lobdell for manuscript review.

Funding: None.


Provenance and Peer Review: This article was commissioned by the Guest Editors (Naleef Fareed, Ann Scheck McAlearney, and Susan D Moffatt-Bruce) for the series “Innovations and Practices that Influence Patient-Centered Health Care Delivery” published in Journal of Hospital Management and Health Policy. The article has undergone external peer review.

Peer Review File: Available at

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The series “Innovations and Practices that Influence Patient-Centered Health Care Delivery” was commissioned by the editorial office without any funding or sponsorship. Dr. KWL is an independent quality consultant for Medtronic Inc. and Abiomed and a recipient of a Duke Endowment Grant-Perfect Care. Dr. JJA is a consultant for Gore Medical & Cryolife and the founder of The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


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doi: 10.21037/jhmhp-20-114
Cite this article as: Lobdell KW, Appoo JJ, Rose GA, Ferguson B, Chatterjee S. Technological advances to enhance recovery after cardiac surgery. J Hosp Manag Health Policy 2021;5:30.

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