Committee Recommendations for Resuming Cardiac Surgery Activity in the SARS-CoV-2 Era: Guidance From an International Cardiac Surgery Consortium

Cardiac Surgery Outcomes During the COVID-19 Pandemic Worsened Across All Socioeconomic Statuses

BACKGROUND

Increasing socioeconomic distress has been associated with worse cardiac surgery outcomes. The extent to which the pandemic affected cardiac surgical access and outcomes remains unknown. We sought to examine the relationship between the COVID-19 pandemic and outcomes after cardiac surgery by socioeconomic status.

METHODS

All patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative, the Virginia Cardiac Services Quality Initiative (2011-2022), were analyzed. Patients were stratified by timing of surgery before vs during the COVID-19 pandemic (March 13, 2020). Hierarchic logistic regression assessed the relationship between the pandemic and operative mortality, major morbidity, and cost, adjusting for the Distressed Communities Index (DCI), STS predicted risk of mortality, intraoperative characteristics, and hospital random effect.

RESULTS

A total of 37,769 patients across 17 centers were included. Of these, 7269 patients (19.7%) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI 37.4 vs DCI 41.9; P < .001) and had a lower STS predicted risk of mortality (2.16% vs 2.53%, P < .001). After risk adjustment, the pandemic was significantly associated with increased mortality (odds ratio 1.398; 95% CI, 1.179-1.657; P < .001), cost (+$4823, P < .001), and STS failure to rescue (odds ratio 1.37; 95% CI, 1.10-1.70; P = .005). The negative impact of the pandemic on mortality and cost was similar regardless of DCI.

CONCLUSIONS

Across all socioeconomic statuses, the pandemic is associated with higher cost and greater risk-adjusted mortality, perhaps related to a resource-constrained health care system. More patients during the pandemic were from less distressed communities, raising concern for access to care in distressed communities.

COVID-19: retrospektive Kapazitätsanalyse in deutschen herzchirurgischen Fachabteilungen

Hintergrund

Um Veränderungen in der herzchirurgischen Patientenversorgung während der COVID-19-Pandemie in Deutschland zu objektivieren, hat die Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG) eine strukturierte Umfrage durchgeführt.

Methode

An dieser Umfrage unter 79 herzchirurgischen Fachabteilungen im Juni 2021 beteiligten sich 53 Fachabteilungen. Folgende Zeitpunkte wurden der Umfrage zugrunde gelegt: 01.01.2020 als Zeitpunkt vor Beginn der COVID-19-Pandemie und der 30.04.1921 als Stichtag für die Datenerhebung. Zu diesem Zeitpunkt war die „dritte Welle“ der Pandemie in Deutschland bereits abgeflaut, und eine Rückkehr zum Routinebetrieb erschien absehbar.

Ergebnis

Am 01.01.2020 standen den 53 teilnehmenden herzchirurgischen Fachabteilungen dauerhaft insgesamt 800 Intensivtherapiebetten zur Verfügung. Mit Stand zum 30.04.2021 hatte sich diese Intensivbettenkapazität um 25,6 % auf 595 reduziert. Auch die Anzahl der OP für herzchirurgische Eingriffe hatte sich während der beiden ersten „Lockdowns“ in Deutschland von 207 vor der Pandemie auf 152 reduziert (−26,6 %). Während der COVID-19-Pandemie wurden stationäre Bereiche umgewidmet, sodass 50,9 % der Teilnehmer angaben, dass ärztliches Personal und in 75,5 % der teilnehmenden Fachabteilungen auch pflegerisches Personal in spezielle COVID-19-Bereiche delegiert wurde.

Schlussfolgerung

Seit Beginn der Coronapandemie im Januar 2020 und dem Auslauf der „dritten Welle“ im Mai 2021 hat sich die herzchirurgische Versorgung in Deutschland erheblich verändert: Dies führte durch Schließung von Intensivbetten und OP in herzchirurgischen Fachabteilungen zu erheblichen Implikationen der Patientenversorgung.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00398-022-00527-5) enthalten.

Effects of the COVID-19 Pandemic on Cardiac Surgery Practice and Outcomes

Background

While the coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of health care, its impact on cardiac surgical practice and outcomes is yet to be determined. We compared the outcomes of our cardiac surgical practice from the past year during the pandemic to those in a similar pre-pandemic period.

Methods

Retrospective data were collected from 307 patients who were involved in all adult cardiac surgical procedures performed between March 2020 and February 2021, which was considered the pandemic period, at Amrita Institute of Medical Sciences, India. These were compared with data from the 1-year period between March 2019 and February 2020. During that earlier period, 491 patients underwent surgery, and the surgical outcomes were assessed. Outpatient visit data were also collected to evaluate the effect of COVID-19 on outpatient follow-up visits.

Results

A 37% decrease in surgical case volume was observed during the study period. No difference was found in operative mortality between the 2 time periods (3.3% vs. 2.6%, p=0.383). Overall postoperative complications were less frequent during this period, at 23% compared to 38% the previous year (p<0.001).

Conclusion

The COVID-19 pandemic caused a dramatic decrease in surgical volume and outpatient medical follow-up. However, the pandemic and its attendant social restrictions did not yield a significant change in the surgical outcomes of our patients. Hence, it is reasonable to continue cardiac surgical care during global health crises, and this can be done with good results.

Impact of the Coronavirus Disease 2019 Pandemic on Cardiac Surgical Education in North America

OBJECTIVE

We report the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiac surgery trainee education in North America.

METHODS

A survey was sent to participating academic adult cardiac surgery centers in North America. Data regarding the effect of COVID-19 on cardiac surgery training were analyzed.

RESULTS

Responses were received from 53 academic institutions with diverse geographic distribution. Cardiac surgery trainee re-deployment to alternative clinical duties peaked at the height of the pandemic. We stratified institutions based on high (n = 20) and low burden (n = 33) of patients hospitalized with COVID-19. The majority of institutions have converted didactics (high burden 90% vs low burden 73%) and interviews for jobs/fellowships (high burden 75% vs low burden 73%) from in-person to virtual. Institutions were mixed in preference for administration of the licensing examination, with the most common preference for examinations to be held remotely on normal timeline (high burden 45% vs low burden 30%) or in person with more than 3-month delay (high burden 20% vs low burden 33%). Despite the challenges experienced during the COVID-19 pandemic on trainee clinical experience, re-deployment, and decreased operative volume, institutions expected their trainees to graduate on schedule (high burden 95% vs low burden 91%).

CONCLUSIONS

Our study demonstrates that actions taken during the COVID-19 pandemic has led to disruptions in cardiac surgery training with transition of didactics and interviews virtually and re-deployment to alternative duties. Despite this, institutions remain optimistic that their trainees will graduate on schedule.

The arrival of COVID-19 in Brazil and the impact on coronary artery bypass surgery

BACKGROUND AND AIM OF THE STUDY

This study analyzed the arrival of coronavirus disease 2019 (COVID-19) in Brazil and its impact on coronary artery bypass grafting (CABG) surgery.

METHODS

Patients undergoing isolated CABG in six hospitals in Brazil were divided into two periods: pre-COVID-19 (March-May 2019, N = 468) and COVID-19 era (March-May 2020, N = 182). Perioperative data were included on a dedicated REDCap platform. Patients with clinical and tomographic criteria and/or PCR (+) for severe acute respiratory syndrome coronavirus 2 infection were considered COVID-19 (+). Logistic regression analysis was performed to create a multiple predictive model for mortality after CABG in COVID-19 era.

RESULTS

Compared to 2019, in 2020, CABG surgeries had a 2.8-fold increased mortality risk (95% confidence interval [CI]: 1-7.6, p = .041), patients who evolved with COVID-19 had a 11-fold increased mortality risk (95% CI: 2.2-54.9, p < .003), rates of morbidities and readmission to the intensive care unit. The surgical volume was decreased by 60%. The model to predict mortality after CABG in the COVID-19 era was validated with good calibration (Hosmer-Lemeshow = 1.43) and discrimination (receiver operating characteristic = 0.78).

CONCLUSION

The COVID-19 pandemic had an adverse impact on mortality, morbidity and volume of patients undergoing CABG.

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.

Coronary artery bypass graft surgery outcomes in the United States: Impact of the coronavirus disease 2019 (COVID-19) pandemic

Objective

There has been a substantial decline in patients presenting for emergent and routine cardiovascular care in the United States after the onset of the coronavirus disease 2019 (COVID-19) pandemic. We sought to assess the risk of adverse clinical outcomes among patients undergoing coronary artery bypass graft (CABG) surgery during the 2020 COVID-19 pandemic period and compare the risks with those undergoing CABG before the pandemic in the year 2019.

Methods

A retrospective cross-sectional analysis of the TriNetX Research Network database was performed. Patients undergoing CABG between January 20, 2019, and September 15, 2019, contributed to the 2019 cohort, and those undergoing CABG between January 20, 2020, and September 15, 2020, contributed to the 2020 cohort. Propensity-score matching was performed, and the odds of mortality, acute kidney injury, stroke, acute respiratory distress syndrome, and mechanical ventilation occurring by 30 days were evaluated.

Results

The number of patients undergoing CABG in 2020 declined by 35.5% from 5534 patients in 2019 to 3569 patients in 2020. After propensity-score matching, 3569 patient pairs were identified in the 2019 and the 2020 cohorts. Compared with those undergoing CABG in 2019, the odds of mortality by 30 days were 0.96 (95% confidence interval [CI], 0.69-1.33; P = .80) in those undergoing CABG in 2020. The odds for stroke (odds ratio [OR], 1.201; 95% CI, 0.96-1.39), acute kidney injury (OR, 0.76; 95% CI, 0.59-1.08), acute respiratory distress syndrome (OR, 1.01; 95% CI, 0.60-2.42), and mechanical ventilation (OR, 1.11; 95% CI, 0.94-1.30) were similar between the 2 cohorts.

Conclusions

The number of patients undergoing CABG in 2020 has substantially declined compared with 2019. Similar odds of adverse clinical outcomes were seen among patients undergoing CABG in the setting of COVID-19 compared with those in 2019.

A 48-Year-Old Man at Low Risk for SARS-CoV-2 Infection Who Underwent Planned Elective Triple-Vessel Coronary Artery Bypass Graft Surgery at a National Heart Center in Indonesia Followed by a Fatal Case of COVID-19

Patient: Male, 48-year-old

Final Diagnosis: Chronic kidney disease • coronary artery disease • COVID-19

Symptoms: Chest pain • fever • shorthness of breath

Medication: —

Clinical Procedure: Coronary artery bypass graft surgery

Specialty: Cardiac surgery

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care.

AIM

To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019.

METHODS

This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications.

RESULTS

With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge.

CONCLUSIONS

Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

Cardiac Surgery Outcomes in an Epicenter of the COVID-19 Pandemic

As New York State quickly became the epicenter of the COVID-19 pandemic, innovative strategies to provide care for the COVID-19 negative patients with urgent or immediately life threatening cardiovascular conditions became imperative. To date, there has not been a focused analysis of patients undergoing cardiothoracic surgery in the United States during the COVID-19 pandemic. Therefore, we seek to summarize the selection, screening, exposure/conversion, and recovery of patients undergoing cardiac surgery during the peak of the COVID-19 pandemic. We retrospectively reviewed a prospectively maintained institutional database for patients undergoing urgent or emergency cardiac surgery from March 16, 2020 to May 15, 2020, encompassing the peak of the COVID-19 pandemic. All patients were operated on in a single institution in New York City. Preoperative demographics, imaging studies, intraoperative findings, and postoperative outcomes were reviewed. Between March 16, 2020 and May 15, 2020, a total of 54 adult patients underwent cardiac surgery. Five patients required reoperative sternotomy and cardiopulmonary bypass was utilized in 81% of cases. Median age was 64.3 (56.0; 75.3) years. Two patients converted to COVID-19 positive during the admission. There was one operative mortality (1.9%) associated with an acute perioperative COVID-19 infection. Median length of hospital stay was 5 days (4.0; 8.0) and 46 patients were discharged to home. There was 100% postoperative follow up and no patient had COVID-19 conversion following discharge. The delivery of cardiac surgical care was safely maintained in the midst of a global pandemic. The outcomes demonstrated herein suggest that with proper infection control, isolation, and patient selection, results similar to those observed in non-COVID series can be replicated.

Perspectives on the COVID-19 pandemic impact on cardio-oncology: results from the COVID-19 International Collaborative Network survey

BACKGROUND

Re-allocation of resources during the COVID-19 pandemic has resulted in delays in care delivery to patients with cardiovascular disease and cancer. The ability of health care providers to provide optimal care in this setting has not been formally evaluated.

OBJECTIVES

To assess the impact of COVID-19 resource re-allocation on scheduling, testing, elective procedures, telemedicine access, use of new COVID-19 therapies, and providers' opinions on healthcare policies among oncology and cardiology practitioners.

METHODS

An electronic survey was conducted by a cardio-oncology collaborative network through regional and state chapters of the American College of Cardiology, American Society of Clinical Oncology, and the International Cardio-Oncology Society. Descriptive statistics were reported by frequency and proportion for analyses, and stratified categorically by geographic region and specialty.

RESULTS

One thousand four hundred fifteen providers (43 countries) participated: 986 cardiologists, 306 oncologists, and 118 trainees/internal medicine. 63% (195/306) of oncologists vs 92% (896/976) of cardiologists reported cancellations of treatments/elective procedures (p = 0.01). 46% (442/970) of cardiologists and 25% (76/303) of oncologists modified the scope of their practice (p = < 0.001). Academic physicians (74.5%) felt better supplied with personal protective equipment (PPE) vs non-academic (74.5% vs 67.2%; p = 0.018). Telemedicine was less common in Europe 81% (74/91), and Latin America 64% (101/158), than the United States, 88% (950/1097) (p = < 0.001). 95% of all groups supported more active leadership from medical professional societies.

CONCLUSIONS

These results support initiatives to promote expanded coverage for telemedicine, increased access to PPE, better testing availability and involvement of medical professional societies to help with preparedness for future health care crisis.

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.

The impact of COVID-19 pandemic on congenital heart surgery practice: An alarming change in demographics

Background

The aim of this study is to investigate the effect of COVID‐19 outbreak on congenital cardiac surgery practice in a single center.

Methods

The first case of COVID‐19 in our country was seen on March 11th, 2020. The patients operated between March 11th, 2019‐and March 10th, 2020 were taken as the pre‐COVID group, and those operated between March 11th and May 11th, 2020 were taken as the COVID group. The data was retrospectively collected, and the two periods were compared.

Results

Monthly average number of cases which was 52 patients/month (626 patients in 12 months) before COVID decreased to 35 patients/month (70 patients in 2 months) during COVID periods (P < .01). During the pre‐COVID period the median postoperative length of hospital stay was 3 (IQR: 1‐5) days. During the COVID period, this decreased to 1 (IQR: 1‐3) day (P < .01). During the pre‐COVID period, the hospital expenses of 17% (8/47) of the foreign nationals were covered by their homeland. The remaining 83% (39/47) were paid from the asylum seekers’ fund. The proportion of foreign nationals operated significantly decreased during the COVID period ([7%; 47/632 vs 1%; 1/70]; P = .04). No significant difference was observed in terms of STAT mortality scores and categories and postoperative results of the operations performed between the two periods.

Conclusions

Congenital cardiac surgery practice can be safely maintained with restricted case volume during the pandemic period. It is alarming that patients in the deprived areas cannot access pediatric cardiac surgery and possibly other health services because of closure of the borders between countries.

Prioritizing elective cardiovascular procedures during the COVID-19 pandemic: The cardiovascular medically necessary, time-sensitive procedure scorecard

BACKGROUND

Following the surge of the coronavirus disease 2019 (COVID-19) pandemic, government regulations, and recommendations from professional societies have conditioned the resumption of elective surgical and cardiovascular (CV) procedures on having strategies to prioritize cases because of concerns regarding the availability of sufficient resources and the risk of COVID-19 transmission.

OBJECTIVES

We evaluated the use of a scoring system for standardized triage of elective CV procedures.

METHODS

We retrospectively reviewed records of patients scheduled for elective CV procedures that were prioritized ad hoc to be either performed or deferred when New Jersey state orders limited the performance of elective procedures due to the COVID-19 pandemic. Patients in both groups were scored using our proposed CV medically necessary, time-sensitive (MeNTS) procedure scorecard, designed to stratify procedures based on a composite measure of hospital resource utilization, risk of COVID-19 exposure, and time sensitivity.

RESULTS

A total of 109 scheduled elective procedures were either deferred (n = 58) or performed (n = 51). The median and mean cumulative CV MeNTS scores for the group of performed cases were significantly lower than for the deferred group (26 (interquartile range (IQR) 22-31) vs. 33 (IQR 28-39), p < .001, and 26.4 (SE 0.34) vs. 32.9 (SE 0.35), p < .001, respectively).

CONCLUSIONS

The CV MeNTS procedure score was able to stratify elective cases that were either performed or deferred using an ad hoc strategy. Our findings suggest that the CV MeNTS procedure scorecard may be useful for the fair triage of elective CV cases during the time when available capacity may be limited due to the COVID-19 pandemic.