Cardiac Surgery and the COVID-19 outbreak: what does it mean?

Cardiac surgeons have a responsibility to ensure that evidence-based, essential cardiac operations are provided to the public, at the same time the wider burden of procedures must be minimized in times of COVID-19.

So what is the impact of COVID-19 outbreak on cardiac surgery? Cardiac surgery practice might not be on the frontline of COVID-19 patient care. However, the pandemic affects cardiac surgery units in important ways: limited intensive care unit (ICU) beds and ventilation sites, necessity to postpone elective and/or complex cardiac surgeries, shortage of health care workers, sick health care staff, restrictions in clinical meetings (e.g. limiting the number of attendees in heart-team meetings), patients developing COVID-19 after cardiac surgery, patients with COVID-19 needing urgent cardiac operations, and cancelation of training and education, professional conferences, exams, courses.As cardiac surgeons, we have a responsibility to ensure that evidence-based, essential cardiac operations are provided to the general public, at the same time the wider burden of those procedures on the healthcare system and health care workers must be minimized in times of COVID-19.

Which cardiac operations should be performed?

In a progressively escalating situation as we now have in most European countries, routine elective cardiac surgery should be stopped. In contrast, in-house urgent cases, who are at risk for adverse cardiac events if going home instead of staying in the hospital, might still undergo cardiac surgery at this time. However, one must consider the risk of exposing these patients to a possible COVID-19 infection during hospitalization and/or exposing health care workers to patients with potential SARS-CoV-2 infection. Most patients with COVID-19 have mild or no symptoms and therefore, it may be difficult to identify such patients in in-house urgent cases (1). We think that patients with acute coronary syndrome in case of severe coronary artery disease (e.g. severe left main trunk stenosis, severe triple vessel disease with high SYNTAX score) who are not eligible for conservative or interventional treatment may be operated on. This may be true also for younger patients with symptomatic severe aortic valve stenosis, left-sided endocarditis with a severe valve defect and/or large mobile vegetation, large ascending aortic aneurysm (>6 cm in diameter), and symptomatic severe mitral valve insufficiency.If the pandemic escalates into a crisis with absolute shortage of ICU beds, cardiac operations may be limited to absolutely essential emergency surgeries, e.g. in case of acute type A aortic dissection, acute heart failure due to severe coronary artery or valvular heart disease, and ventricular septal defect. Under such circumstances, even those decisions are not obvious and should be made depending on available resources and supported by an ethical and legal framework.

Elective patients: should their care be delayed?

One must realize that cardiac surgery units have a responsibility to the patient, but also to the health care workers and the wider health care service in a region/country. Therefore, in an escalating pandemic, patients with elective cardiac procedures may be best managed by delaying their care until a few weeks or even months later. This may be in the patient`s best interest, such as not to be exposed to the hospital environment and not to incidentally develop COVID-19 in the postoperative course. It is known that patients with acute coronary syndrome who are infected with SARS-CoV-2 often have a poor prognosis (1). Therefore, developing COVID-19 after cardiac surgery might be associated with a high mortality.

How to protect limited and sick health care staff?

Health care workers are among those at high risk of infection with COVID-19 (2). As such, precautions in the care of all patients and in the interactions between health care workers are of high priority.First, staff management can take appropriate measures to separate workers/surgeons into groups, so that possible quarantines can be applied to groups within each unit rather than the unit as a whole, which would lead to the closure of the entire service. This is especially true for smaller cardiac surgery units.Second, it must be known that SARS-COV-2 is spread by droplets and contact (2). The virus is not principally an airborne virus. Therefore, the Center for Disease Control and Prevention (CDC) recommends the use of gowns, pairs of gloves, and an N95 respirator plus a face shield and/or googles when treating patients with COVID-19 (2). No data is available on whether N95 masks are needed in the OR to effectively protect surgical staff or if surgical masks are enough. However, since manipulation of the airway and/or esophagus are considered high risk for producing aerosols composed of smaller virus-containing particles, which are suspended in the air and can be inhaled, we think that N95 masks should be recommended (2, 3). This is especially true if COVID-19 patients undergo emergency cardiac surgery. Operative theatre doors should be shut at all times, negative pressure rooms would be optimal. After surgery, before leaving, contaminated equipment must be left in the OR and discarded into a container. It might be important not to push the equipment down into the container to avoid releasing aerosols, which could be contaminated (2, 3). Googles should be disinfected with wipes impregnated with a wide spectrum agent to disinfect surfaces. Importantly, the coronavirus is known to live on surfaces for hours to days, but it is also effectively killed by available disinfectants when properly used (4). Health care workers must focus on meticulous hand hygiene, avoiding contaminating workspaces and should clean workspaces and personal items.

COVID-19 in health care workers and patients?

The consequences of delayed recognition of a patient with COVID-19 are significant (2). Recognizing that symptoms of COVID-19 may be mild, and can present with heart palpations and chest tightness rather than with respiratory symptoms, such as fever and cough, its diagnosis in patients after cardiac surgery or health care workers can be difficult (1). Those patients with symptoms of suspected COVID-19 should be tested and rapidly separated in an isolation room. It must be mentioned that patients with COVID-19 can experience elevated levels of cTnI or cardiac arrest during hospitalization (1). This is most probably owed to the systemic inflammatory response and immune system disorder during disease progression.When health care workers exhibit respiratory symptoms, they should not provide direct patient care and be tested for SARS-CoV-2. Whether or not they should continue working, using surgical masks, until the test results are available, is a matter of debate, but theoretically they should not. The problem is that there will be a shortage of health care workers, and one cannot dispense with those who will ultimately test negative. If tested positive for SARS-CoV-2, health care workers must stay home and quarantine immediately.

Cancelation of training, conferences, exams?

Recognizing the risk of health care workers shortages, health services and organizations are banning travel to medical meetings, canceling conferences, limiting internal and external meetings, restricting travel and even setting up a holiday lock to keep caregivers close and available (2). Avoiding travel and crowds decreases the risk of infection even further.While cardiac surgery training and education for residents will be put on hold, these extraordinary times are also an opportunity to demonstrate outstanding collaboration within a hospital, special staff management, emergency planning, sense of responsibility, innovative ways for outpatient care through telemedicine, virtual meetings and conferences and after all, medical leadership in extraordinary circumstances.

Conclusions

The COVID-19 pandemic puts health services including cardiac surgery units under escalating pressure. Cardiac surgeons and associated health care staff are confronted with a novel virus and disease that leads to great uncertainty. How is SARS-CoV-2 spread, what should be done and what should be avoided, how can we protect the patient and health care workers?It is crucial to provide a thoughtful decision making process on whether or not a cardiac surgery should be performed. Decisions made today may be different from those made only a few days later under these rapidly changing circumstances. One must weigh the risk of delaying surgical care with the risk of exposing the patient to the hospital environment and the risk of developing COVID-19, and this in the context of a health care system under enormous pressure. Of outmost importance, we must recognize that health care workers are of high risk for COVID-19. This puts not only health care workers at increased risk of infection, but also their family members. Hospitals must provide maximum protective equipment and training on how to us it to health care workers. Patients can only be treated if health care workers stay healthy.

References

1. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020 Mar 5.2. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA. 2020 Mar 12.3. Romaguera R, Cruz-González I, Ojeda S, Jiménez-Candil J, Calvo D,García Seara J, Cañadas-Godoy V, Calvo E, Brugaletta S, Sánchez Ledesma M, Moreno R. Consensus document of the Interventional Cardiology and Heart Rhythm Associations of the Spanish Society of Cardiology on the management of invasive cardiac procedure rooms during the COVID-19 coronavirus outbreak. REC Interv Cardiol 20204. Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT, Wong MSY, Marimuthu K. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. 2020 Mar 4.AcknowledgmentsWe would like to thank Silvia Matt, PhD, for language editing