The Rapid Transformation of Cardiac Surgery Practice in the Coronavirus Disease 2019 (COVID-19) Pandemic: Insights and Clinical Strategies From a Center at the Epicenter

Effect of COVID-19 Pandemic on Complications and Mortality in the Early Postoperative Period After Heart Transplantation

INTRODUCTION

The coronavirus disease 2019 (COVID-19) outbreak directly impacted heart transplantation (HT) surgery activity. Reallocating resources and converting surgical intensive care units to COVID-19 facilities led to reduced accessibility and quality of health care facilities to heart recipient patients.

AIM

To study the effect of the COVID-19 pandemic on heart transplantation activity and outcomes in the early postoperative period.

METHODS

Retrospective data analysis of patients undergoing orthotopic heart transplantation in our institution from March 2018 to February 2022. The patient population (N = 281) included 223 (79.4%) men and 58 (20.6%) women. The perioperative data of the prepandemic group, March 2018 to February 2020 (N = 130), and the pandemic group, March 2020 to February 2022 (N = 151), were compared.

RESULTS

We found differences in preoperative inotropic support between the groups (N = 43 (33.1%) vs N = 72 (47.7%), P < .05), respectively). The number of urgent HTs increased during the COVID-19 pandemic (N = 51 (39.2%), vs N = 72 (47.7%), P = .155). Analyzed groups did not differ according to renal, pulmonary, or neurology complications. Intensive care unit (ICU) standing time was longer in the pandemic group (6 days [3-12] vs 11 days [5-12], P < .001).

CONCLUSION

We found that during the COVID-19 pandemic, the number of end-stage heart failure recipients requiring cardiac support increased. Extended time of ICU standing in the pandemic group may be related to the COVID-19 pandemic. Although some efforts have been made to reduce the impact of the pandemic, more research is required.

Cardiac surgery during the COVID-19 pandemic

The COVID-19 pandemic had several specific as well as general implications on cardiac surgery. Acute respiratory distress made extracorporeal oxygenation necessary in a significant number of patients and accordingly many patients were treated in anesthesiological and even more in cardiac surgical intensive care units, which left only a limited number of beds in the intensive care units available for elective surgery cases. Moreover, the necessary availability of intensive care beds for severely diseased COVID-19 patients in general posed a further limit, as did the relevant number of diseased personnel. Specific emergency plans were developed for many heart surgery units, limiting the number of elective cases. Increasing waiting lists were of course stressful for numerous elective-surgery patients and the decreased number of heart operations also meant a financial burden for many units.

Non-interventional Feasibility Assessment for Fast-Track Cardiac Anesthesia

Background The introduction of fast-track extubation procedures following cardiac surgery has significantly shortened hospitalization duration in intensive care units (ICUs). Early extubation is the most crucial step in getting out of the ICU early and providing ideal patient circulation. In times of crisis such as pandemics, it is vital to provide rapid flow through the hospital to prevent the postponement or inability to operate on patients awaiting surgery. This study aimed to determine the obstacles to early extubation in patients undergoing cardiac surgery and the perioperative characteristics that were affected in terms of fast-track extubation. Methodology This was an observational, cross-sectional study with data collected prospectively from October 1 to November 30, 2021. Preoperative data and comorbidities were recorded. Intraoperative and postoperative data were recorded and analyzed. Intraoperative cross-clamp duration, cardiopulmonary bypass duration, length of operation, and erythrocytes (red blood cells) transfused were recorded for each patient. Early postoperative clinical conditions were defined in patients whose mechanical ventilation duration exceeded eight hours (such as pulmonary complications, cardiovascular complications, renal complications, neurological conditions, and infective complications ). The length of ICU stay (hours), length of hospital stay (days), return to the ICU, reasons for return to the ICU, and overall hospital mortality were investigated. A total of 226 patients were included in the study. Patients were divided into two groups: extubated within eight hours (FTCA, fast-track cardiac anesthesia) and late extubation (after eight hours) postoperatively, and the data were evaluated accordingly. Results While 138 (61.1%) of the patients were extubated in eight hours or less, 88 (38.9%) patients were extubated after more than eight hours. The most common complications (55.7%) in patients with late extubation were cardiovascular complications, followed by respiratory complications (15.9%), and the surgeon's refusal (15.9%). In the logistic model created with the independent variables affecting the extubation time, the American Society of Anesthesiologists score and red blood cell transfusion were risk factors for longer extubation time. Conclusions In our research to reveal the feasibility of and barriers to FTCA, it was found that cardiac and respiratory problems were the most common reasons for delayed extubation. Due to the refusal of the surgical team, it was observed that some patients remained intubated despite meeting the FTCA requirements. It was considered the most improvable obstacle. Regarding cardiovascular complications, the team should aim to optimally control patient comorbidities in the preoperative period, reduce the use of red blood cell transfusions, and ensure that the entire team is updated on current extubation protocols, in particular surgeons and anesthesiologists.

Noteworthy Cardiac Literature From 2021: Coronary Guideline Change Without New Data, Heart Transplant Donation After Cardiac Death, Covid Effects on Global Cardiac Surgery, and Attempt to Improve Dissection Remodeling

Cardiac surgery continues to evolve. The last year has been notable for many reasons. The guidelines for coronary revascularization introduced significant discord. The pandemic continues to affect the care on a global scale. Advances in organ procurement and dissection care move forward with better understanding and better technology.

Application of Different Ventilation Modes Combined with AutoFlow Technology in Thoracic Surgery

To investigate the effect of AutoFlow on airway pressure and hemodynamics in mechanical ventilation constant volume-control ventilation mode, 100 patients receiving mechanical ventilation were randomly divided into observation group (SIMV-PSV-PEEP + AutoFlow) and control group (SIMV-PSV-PEEP). The results showed that the peak airway pressure and average airway pressure decreased with different flow rate settings and automatic flow conversion (P < 0.05). The peak airway pressure and mean airway pressure decreased with different resistance settings (P < 0.05). With different compliance settings, the peak airway pressure and average airway pressure decreased after being assisted with an automatic converter (P < 0.05). Adding AutoFlow on the basis of SIMV-PSV mode can significantly reduce peak inspiratory pressure (PIP), mean airway pressure (Pmean), and airway resistance (R). There was no significant difference in hemodynamic monitoring results between the observation group and the control group. It is proved that the SIMV constant volume-controlled ventilation mode combined with AutoFlow can not only ensure tidal volume but also avoid excessive airway pressure, which has little effect on hemodynamics.

Providing safe perioperative care in cardiac surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.

Impact of COVID-19 on the surgical volume of general surgery residents as main surgeons in a National Training Program in Costa Rica: A cross-sectional study

ABSTRACT

To quantify the impact of coronavirus disease 19 (COVID-19) on the surgical volume of residents' medical practice in Costa Rica's General Surgery Residency Program.The COVID-19 pandemic has caused a significant disruption in people's lives. Health systems worldwide have been forced to adapt to the new normal, which has posed a challenge for medical residency programs, especially in the surgical field.This transversal study includes the surgical records of all residents of the General Surgery program who worked as main surgeons at the Mexico Hospital of the Costa Rican Social Security between December 23, 2019, and June 25, 2020.As main surgeons, a total of 10 residents performed 291 pre-pandemic surgeries and 241 pandemic surgeries.When comparing the distribution of procedures performed by residency levels, it is observed that the postgraduate year -2 increased the number of procedures performed during the pandemic period (pre-pandemic 19% vs pandemic 27%, P = .028). There was no statistically significant difference between the pre-pandemic and pandemic periods in the remaining levels.When comparing the procedures by unit, a statistically significant decrease was observed in the Endocrine-Abdominal Wall Unit (pre-pandemic 18.3% vs pandemic 5.4%, P < .001). Conversely, a statistically significant increase was identified in Surgical Emergencies Unit procedures (40.0% vs post 51.7%, P = .007). No statistically significant differences were observed in the remaining the Units.The COVID-19 pandemic had no statistically significant effect on surgeries performed by residents of the General Surgery Residency Program as main surgeons in a national training center in Costa Rica. The Department's timely measures and pro-resident attitude were the key reasons for the above results.

Redeployment of Health Care Workers in the COVID-19 Pandemic: A Qualitative Study of Health System Leaders' Strategies

OBJECTIVES

This study aimed to determine the strategies used and critical considerations among an international sample of hospital leaders when mobilizing human resources in response to the clinical demands associated with the COVID-19 pandemic surge.

METHODS

This was a cross-sectional, qualitative research study designed to investigate strategies used by health system leaders from around the world when mobilizing human resources in response to the global COVD-19 pandemic. Prospective interviewees were identified through nonprobability and purposive sampling methods from May to July 2020. The primary outcomes were the critical considerations, as perceived by health system leaders, when redeploying health care workers during the COVID-19 pandemic determined through thematic analysis of transcribed notes. Redeployment was defined as reassigning personnel to a different location or retraining personnel for a different task.

RESULTS

Nine hospital leaders from 9 hospitals in 8 health systems located in 5 countries (United States, United Kingdom, New Zealand, Singapore, and South Korea) were interviewed. Six hospitals in 5 health systems experienced a surge of critically ill patients with COVID-19, and the remaining 3 hospitals anticipated, but did not experience, a similar surge. Seven of 8 hospitals redeployed their health care workforce, and 1 had a redeployment plan in place but did not need to use it. Thematic analysis of the interview notes identified 3 themes representing effective practices and lessons learned when preparing and executing workforce redeployment: process, leadership, and communication. Critical considerations within each theme were identified. Because of the various expertise of redeployed personnel, retraining had to be customized and a decentralized flexible strategy was implemented. There were 3 concerns regarding redeployed personnel. These included the fear of becoming infected, the concern over their skills and patient safety, and concerns regarding professional loss (such as loss of education opportunities in their chosen profession). Transparency via multiple different types of communications is important to prevent the development of doubt and rumors.

CONCLUSIONS

Redeployment strategies should critically consider the process of redeploying and supporting the health care workforce, decentralized leadership that encourages and supports local implementation of system-wide plans, and communication that is transparent, regular, consistent, and informed by data.

Literature-based considerations regarding organizing and performing cardiac surgery against the backdrop of the coronavirus pandemic

BACKGROUND

The ongoing coronavirus disease 2019 (Covid-19) pandemic presents challenges for surgeons of all disciplines, including cardiologists. The volume of cardiac surgery cases has to comply with the mandatory constraints of healthcare capacities. The treatment of Covid-19-positive patients must also be considered. Unfortunately, no scientific evidence is available on this issue. Therefore, this study aimed to offer some consensus-based considerations, derived from available scientific papers, regarding the organization and performance of cardiac surgery against the backdrop of the Covid-19 pandemic.

METHODS

Key recommendations were extracted from recent literature concerning cardiac surgery. RESULTSː Reducing elective cardiac procedures should be based on frequent clinical assessment of patients on the waiting list (every one or two weeks) and the current local status of the Covid-19 pandemic. Screening tests at admission for every patient are broadly recommended. Where appropriate, alternative treatment methods can be considered, including percutaneous techniques and minimally invasive surgery, if performed by experienced cardiac surgery teams.

CONCLUSIONS

There is little evidence on the strategies to organize cardiac surgery in the Covid-19 pandemic. Most authors agree on reducing elective operations based on patients' clinical condition and the status of the Covid-19 pandemic. Admission screenings and the use of percutaneous or minimally invasive approaches should be preferred to reduce in-hospital stays.

COVID 19- Perspective of an Italian Center

Italy has been hard hit by severe acute respiratory syndrome coronavirus 2 infection with more than 240,000 cases and 35,000 deaths. During the acute phase of the pandemic, the Italian government decided on the lockdown which lasted about 2 months. During this period, all surgical activities were limited to nondeferable procedures only. The sudden closure posed problems with the management of the heart surgery waiting which at that time included 135 patients. Among these were selected cases with the worst clinical characteristics that were progressively operated on. Compared with a similar period in 2019, the cardiac surgery activity of the "Lancisi Cardiovascular Center" in Ancona has been reduced by 65%. With pandemic mitigation, heart surgery activity has gradually resumed but many open questions remain. Above all, there is the problem of living with a low but persistent level of presence of the virus with the need to organize the activity to ensure patients and staff safety and an optimal level of performance.