The COVID-19 pandemic has caused disruptions to healthcare services across the globe. Cardiac surgery is no exception. In order to preserve supplies and to prepare for continual surges of COVID-19 patients, the U.S. Centers for Medicare and Medicaid Services (CMS) asked hospitals to defer nonessential surgeries. Many other countries also instituted similar deferrals, and surgical societies have scrambled to develop triage standards to determine which surgeries can be postponed and which cannot. Cardiac surgery has been disproportionately affected by these decisions. The reasons for this are multi-layered.
Delays in cardiac surgery for nonemergent (but no less urgent) cardiac cases were intended to:
Cardiac surgery patients are more likely to have comorbidities that, in COVID-19 cases, are associated with poorer clinical outcomes. As such, many cardiologists and cardiothoracic surgeons, during the beginning of the pandemic, had to weigh their patient’s likelihood of contracting COVID-19 against their likelihood of serious complications from delayed surgery.
Upon the outbreak of the pandemic, the Canadian Society of Cardiac Surgeons released a guidance statement for cardiac surgeons suggesting:
In one region of Italy, 16 out of 20 cardiac surgical units discontinued services with urgent cases being diverted to four centralized units.
The European Society of Cardiology noted in a guidance document that all cardiovascular patients in the hospital should be protected from exposure to COVID-19 due to the worse outcomes these patients could experience. The society also recommends that all elective admittance for diagnostic or therapeutic procedures be avoided during the pandemic and that cardiovascular patients have the shortest possible hospital stays.
For surgical procedures, the society recommends that “all elective ablation and cardiac device implantation procedures should be postponed, and antiarrhythmic medications should be reviewed and intensified if necessary.”
Hospitals should develop and implement comprehensive screening procedures to identify patients at increased risk for COVID-19 as cardiac surgical programs begin to ramp up. These include the following:
Fear of becoming infected with the virus may lead some patients to delay seeking necessary cardiac care. According to the CDC, about 40% of adults in the U.S. avoided or delayed medical care during the summer of 2020, due to fear of contracting COVID-19.
Not only were surgeries delayed or canceled, but testing for cardiovascular diseases was also delayed or skipped. To combat this, the American College of Cardiology issued a statement reiterating the safety of hospitals and the importance of seeking emergent care if needed.
Researchers found that “procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020 worldwide. Specifically, transthoracic echocardiography decreased by 59%, transesophageal echocardiography by 76% and stress tests by 78%. Coronary angiography (invasive or computed tomography) decreased 55%.”
“These findings raise serious concerns for long-term adverse cardiovascular health outcomes resulting from decreased diagnosis,” said Andrew J. Einstein, MD, Ph.D., lead author of the study, associate professor of medicine at Columbia University Vagelos College of Physicians and Surgeons, and a cardiologist at New York-Presbyterian/Columbia University Irving Medical Center. “Efforts to improve timely patient access to cardiovascular diagnosis in this and future pandemics, particularly in low- and middle-income countries, are warranted.”
In order for patients to get the care they need, they need to feel that the facility where they are receiving care is safe and following COVID-19 safety protocols. In addition to having preoperative screening measures in place and a post-operative plan for patient safety, your hospital should clearly communicate its safety measures.
One case study where Italian doctors highlight a COVID-19 outbreak at the beginning of the pandemic that specifically affected cardiac patients serves as a worthwhile study to understand the unique complications that post-operative cardiac patients face if they contract COVID-19. Maria Eleonora Hospital, GVM Care & Research, a tertiary cardiovascular hospital in Palermo, was a unit that was deemed COVID-free and safe to continue necessary cardiac surgery. As this was at the beginning of the pandemic, there was insufficient access to tests for the COVID-19 virus so patients were allowed surgery after temperature screening and questionnaires about contact with other COVID-19 patients.
The facility had 55 inpatients at the time and the outbreak affected 20 of those patients. Three patients died, 13 experienced varying degrees of acute kidney injury, and 2 experienced respiratory failures.
Of the 17 surviving COVID-19 patients, nine were moved to a quarantined hotel because they did not require additional medical attention. The remaining eight patients were admitted to the COVID-19 Department of Internal Medicine of Civico Hospital.
One patient, who underwent double-valve replacement and coronary artery bypass grafting, spiked a fever after the procedure. She was transferred to the rehabilitation ward where she tested positive for COVID-19 via nasal swab. After two days, the patient experienced severe and rapid deterioration of respiratory symptoms and required mechanical ventilation. She was weaned from ventilation 10 days later but died as a result of unrecognized sternal bleeding while in isolation. The study authors note that the need for prolonged mechanical ventilation may cause sternal wound problems for this particular subset of surgical patients, so wound closure should be carefully monitored.
Another COVID-19-positive patient died two days after undergoing an aortic valve and ascending aorta replacement procedure as a result of acute kidney dysfunction followed by multiorgan failure.
The study authors note that it is impossible to know whether some of these patients had contracted COVID before or after surgery, but this highlights the care that must be taken both pre-screening and assuring the safety of patients from infection post-surgery.
The American College of Surgeons has several resources for you to better improve communication with your patients during the pandemic. They feature patient handouts and a worksheet for surgeons to help consider common responses to patient questions. You can access the resources here.
Aside from potentially infecting healthcare staff, active COVID-19 infections — even in asymptomatic patients — may lead to unfavorable outcomes. This can be due to the overproduction of proinflammatory cytokines in the post-operative period. Preliminary studies have shown that patients who have established cardiovascular diseases have a greater risk for severe COVID-19 infection and prognosis.
Cardiac Surgery Post-operative Outcomes with COVID-19 Infection. Several studies have found:
The American College of Surgeons has recommended that COVID-19 testing be conducted via PCR/nucleic acid amplification or considered prior to surgery. The College also recommends that providers:
Once cardiac patients are finally in the hospital, it is more important than ever to assure that the surgery is performed meticulously the first time to avoid re-operations, which could expose patients to additional COVID-19 infection risk. Hosts of quality assurance tools are available during surgery, but one essential tool, transit-time ultrasound flow measurements, ensures that bypass grafts are functional with adequate flow before closing. In a landmark 2020 study of saphenous vein grafts by preeminent cardiothoracic surgeons, measurement of intraoperative flow is cited as a vital tool to allow the surgeon to check the patency of grafts during the procedure to provide an opportunity to correct an issue intraoperatively before closure of the patient.
In light of the particularly grave circumstances that face cardiac patients who develop COVID post-operatively, avoidance is something that should be planned for well ahead of the actual surgical procedure. Surgical patients who are negative for COVID should be cared for in an isolated wing of the hospital away from COVID-19 positive or presumed positive patients. Patients who are positive or presumed positive should be placed in a separate ward in an airborne infection isolation room, should have limited traffic to their room, and the amount of healthcare workers who care for or enter the patient’s room should be limited, according to the American College of Surgeons. The college notes: “Post-operative care should also include avoidance of noninvasive positive-pressure ventilation (continuous positive airway pressure and bi-level positive airway pressure) and appropriate PPE (N95 respirator or powered air-purifying respirator) for AGPs (bronchoscopy and chest tube placement). The ICU team should remind all personnel entering the patient’s room about these precautions, especially before any additional procedures.”
Once discharged, COVID negative patients should take advantage of virtual care options for follow-up and questions and follow the isolation precautions set forth by the CDC. The Mayo Clinic advises its post-op patients to:
In order to avoid the consequences of delayed cardiac surgery, it will be important for cardiac surgical services to ramp up the ability to see and treat patients. Adequate campaigns to assure patients of their safety as well as pre-screening for COVID, intraoperative care that assures surgical success the first time, and detailed post-op and home care planning that helps patients to avoid COVID infection is needed.