Cardiothoracic surgery in the COVID era: Revisiting the surgical algorithm

M. Kulasekaran^*

Senior consultant Cardio Thoracic Vascular Surgeon, Kauvery Hospital, Heartcity, Trichy,India

Background

The COVID-19 pandemic has led to unprecedented challenges on a global scale that has not been seen for many years. The COVID-19 illness is highly contagious and lack effective treatment guideline. While the healthcare systems are already overwhelmed, the surgical needs and clinical outcomes were not well evaluated. For effective surgical care to all patients during the outbreak and for COVID-19 patients, the healthcare workforce has to restructure the surgical guidelines.

The cardiac surgery is a highly invasive procedure. The accrued risk of mortality and morbidity in not performing cardiac surgery is paramount. Deferring cardiac procedures can result in detrimental consequences due to the progressive nature of the disease. In addition, the COVID-19 transmission to the patient and the healthcare worker imparts several challenges. The access to surgical care during pandemic and optimizing the surgical platform needs to be evaluated.

Our Experience

‘FIRST WAVE’ of COVID-19

The COVID-19 pandemic has vastly affected the routine hospital services worldwide.In this pandemic, the hospitals have reduced elective operations for mitigating in-hospital viral transmissions and potential COVID-19 related pulmonary complications. Postponement of elective surgeries were undertaken to reduce the exposure of patients and healthcare workers to COVID-19, allocate staffs to emergency and intensive care units and for handling the overwhelmed infrastructure. However, delaying elective surgeries often lead to substantial deterioration in health, reduced quality of life and unnecessary deaths. Limited guidelines are currently available for cardiac surgery patients. Cardiac surgery requires extensive perioperative and postoperative care, hence we proposed a protocol for our experience which aided in making clinical decision.

Institution specific recommendations

Manpower management: The highly specialized cardiac surgery team including the Cardiac surgeon, Cardiologist,Anaesthetist, Pulmonologist and the staffs were divided into two groups and they were deployed in rotation for a period of two weeks to prevent the whole team from acquiring COVID-19 infection. In that two weeks’ period, the healthcare team rendered patient service for one week and the following one week was allocated for self-isolation.
Patient management:We followed The Society of Thoracic Surgeons (STS) guidelines which aided us in deciding the cardiac procedures for patients in this contemporary COVID situation [1].
Screening for COVID-19 before surgery:Testing for COVID-19 in all patients for surgery was made mandatory since COVID-19 is highly transmissible disease and 60% of the patients are asymptomatic. Patients with negative RT-PCR test for COVID but remarkable findings in HRCT Chest scan were identified as the Suspected COVID-19 patients. Their screening algorithm has been illustrated in Fig. 2. The mortality and morbidity associated with COVID illness has been reported to be high as 25%, if an active patient undergoes surgery.
Perioperative care:Elective surgery was postponed for active COVID-19 patients till complete recovery from the infection as the postoperative mortality and morbidity is high. In case of patients requiring emergency surgery, high-risk surgery was performed for life-saving purposes and is the patients critical illness is not attributable to COVID-19. We followed COVID-19 precautions using PPE kit and face shield.

Table 1. Preoperative COVID screening protocol

Days	Investigation
Day 1	RT-PCR test
Day 2 and 3	In-hospital observation for symptoms
Day 4	HRCT chest scan
Day 5	Cardiac Surgery

If any patient develops COVID-19 symptom in the screening period or if the HRCTChest is suspicious then repeat RT-PCR is performed.

Fig. 1. Screeing protocol for Suspected COVID-19 patients.

‘SECOND WAVE’ of COVID-19

India became the new epicentre in the second wave of COVID-19 infection. India had witnessed 26 million COVID-19 positive patients second only to US and imposed an unparalleled strain on the patients undergoing cardiothoracic surgery and also for the healthcare team. The Indian Association of Cardio-Thoracic Surgeons (IACTS) has proposed a set of guidelines for screening cardiac patients for surgery [2]. Hence a more robust screening protocol for patient selection and timing of cardiac surgery is much needed.

Fig. 2. Cardiac patients during the pandemic.

Effects of COVID-19 on Cardiovascular System

From the first wave of COVID-19 illness, it was recognized that COVID-19 chiefly affects the respiratory system. However, it has been reported that COVID-19 can affect the cardiac system leading to myocardial injury and endothelial dysfunction. Additionally, it has been reported that COVID-19 may cause cardiac damage even without clinical features of respiratory impairment [3-4]. We operated on 56 post-COVID patients at our centre. We evaluated the cardiac patients for COVID-19 and the attender was also tested for COVID-19 in order to prevent transmission of illness and only one attender was allowed to stay with the patient.

A total of 53 patients had uneventful recovery (53/56, 94.6%). Majority of the patients were admitted for CABG (82.1%) followed by MVR (3 patients, 5.4%) and 3 patients (5.4%) had mortality during hospitalisation.

Fig. 3. Age distribution of Cardiac patients during the pandemic.

Fig. 4. Surgeries performed during pandemic.

Conclusion

To summarize, the overall COVID-19 patients undergoing surgery has been reduced in this pandemic. There is huge risk of acquiring perioperative COVID-19 infection in patients experiencing surgery especially during the pandemic. However, the risks have to be weighed against the risk of deferring time-sensitive surgeries. Preoperative screening for SARS CoV-2 prevents less complications attributed to COVID illness. With the COVID illness evolution, the Cardiac Surgeons have gained enormous experience for embracing the possibility of repeat waves of COVID-19 infection.

References

Haft JW, Atluri P, Ailawadi G, et al. Adult cardiac surgeryduring the COVID-19 pandemic: A tiered patient triage guidance statement. J Thorac Cardiovasc Surg. 2020;160(2):452-5.
Hiremath CS, Yadava OP, Meharwal ZS, et al. IACTS guidelines: practice of cardiovascular and thoracic surgery in the COVID-19 era. Indian J Thorac Cardiovasc Surg Off Organ, Assoc Thorac Cardiovasc Surg India. 2020;36(5):438.
Madjid M, Safavi-Naeini P, Solomon SD, et al. Potential effectsof coronaviruses on the cardiovascular system: A review. JAMA Cardiol. 2020;5(7):831-40.
Basu-Ray I, Almaddah NK, Adeboye A, et al. Cardiac Manifestations Of Coronavirus (COVID-19). StatPearls 2021. Available from:

Dr. M. Kulasekaran

Senior consultant Cardio Thoracic Vascular Surgeon

Cardiothoracic surgery in the COVID era: Revisiting the surgical algorithm

Cardiothoracic surgery in the COVID era: Revisiting the surgical algorithm

Dr. M. Kulasekaran

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