Cardiac surgery in North America and coronavirus disease 2019 (COVID-19): Regional variability in burden and impact

Trends in major adverse cardiac events and healthcare utilization during the COVID-19 pandemic in Alberta, Canada

Background

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in Canada. The COVID-19 pandemic altered the usual care of ambulatory and acute cardiac patients. This study aimed to describe ASCVD-related clinical outcomes and healthcare resource utilization (HCRU) patterns during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada, relative to the three preceding years.

Methods

A repeated cross-sectional study design was conducted over three-month periods using administrative health data between March 15, 2017, and March 14, 2021. ASCVD-related clinical outcomes included major adverse cardiovascular events (MACE) endpoints. HCRU was assessed through general practitioner and other healthcare professional visits (including telehealth claims) for ASCVD events, emergency department visits, ASCVD diagnostic imaging tests, laboratory tests, and hospital length of stay.

Results

Relative to the control year period (March to June 2019) ASCVD-related events (i.e., hospitalizations, emergency department (ED) visits and physician office visits) declined by 23% during the three-months COVID-19 period (March to June 2020). Acute declines were not sustained following June 2020. In contrast, in-patient mortality rates involving a primary MACE endpoint increased from March to June 2020 COVID-19 period.

Conclusions

This study demonstrates the COVID-19 pandemic and corresponding public health restrictions impacted ASCVD-related care. While many clinical outcomes returned to pre-pandemic levels at the end of the observation period, our results suggest that patients' HCRU declined, which could lead to further CV events and mortality. Understanding the impact of COVID-19 restrictions on ASCVD-related care may help improve healthcare resiliency.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Impact of Pandemic Response on Training Experience of Anesthesiology Residents in an Academic Medical Center: A Retrospective Cohort Study

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

Persistent Depletion of Neuroprotective Factors Accompanies Neuroinflammatory, Neurodegenerative, and Vascular Remodeling Spectra in Serum Three Months after Non-Emergent Cardiac Surgery

We hypothesized that the persistent depletion of neuroprotective markers accompanies neuroinflammation and neurodegeneration in patients after cardiac surgery. A total of 158 patients underwent elective heart surgery with their blood collected before surgery (t_baseline) and 24 h (t_24hr), seven days (t_7d), and three months (t_3m) post-surgery. The patients’ serum was measured for markers of neurodegeneration (τau, τaup181–183, amyloid β1-40/β2-42, and S100), atypical neurodegeneration (KLK6 and NRGN), neuro-injury (neurofilament light/heavy, UC-HL, and GFAP), neuroinflammation (YKL-40 and TDP-43), peripheral nerve damage (NCAM-1), neuroprotection (apoE4, BDNF, fetuin, and clusterin), and vascular smoldering inflammation (C-reactive protein, CCL-28 IL-6, and IL-8). The mortality at 28 days, incidence of cerebrovascular accidents (CVA), and functional status were followed for three months. The levels of amyloid β1-40/β1-42 and NF-L were significantly elevated at all time points. The levels of τau, S100, KLK6, NRGN, and NCAM-1 were significantly elevated at 24 h. A cluster analysis demonstrated groupings around amyloids, KLK6, and NCAM-1. YKL-40, but not TDP-43, was significantly elevated across all time points. BDNF, apoE4, fetuin, and clusterin levels were significantly diminished long-term. IL-6 and IL-8 levles returned to baseline at t_3m. The levels of CRP, CCL-28, and Hsp-70 remained elevated. At 3 months, 8.2% of the patients experienced a stroke, with transfusion volume being a significant variable. Cardiac-surgery patients exhibited persistent peripheral and neuronal inflammation, blood vessel remodeling, and the depletion of neuroprotective factors 3 months post-procedure.

Two hundred robotic mitral valve repair procedures for degenerative mitral regurgitation: the Yale experience

Background

Robotic surgery has gained popularity over the past two decades due to the benefits related to smaller surgical incisions, enhanced technical dexterity and better intraoperative visualization. We present the Yale experience of the first two hundred totally endoscopic, robotic-assisted mitral valve repair procedures for the treatment of degenerative mitral regurgitation.

Methods

We performed a retrospective cohort study of patients undergoing totally endoscopic, robotic-assisted isolated or concomitant mitral valve repair for degenerative mitral regurgitation at Yale-New Haven Hospital from October 2018 to April 2022. Mitral valve repair procedures for rheumatic or secondary functional mitral regurgitation and planned robotic-assisted mitral valve replacement cases were excluded.

Results

Two hundred consecutive procedures were performed. The median age was 65 years (interquartile range, 58-73 years). Six patients (3.0%) had a history of mediastinal radiation, four patients (2.0%) had previous cardiac surgery, and one patient (0.5%) had cardiac dextroversion. Median cardiopulmonary bypass and aortic cross-clamp times were 122 and 79 minutes, respectively. Femoral vessel cannulation was performed percutaneously in 57 (28.5%) patients with no major access-site related complication. Aortic cross-clamping was performed with the endoaortic balloon occlusion device in 151 (75.5%) patients. No conversions to sternotomy occurred. Satisfactory repair was achieved in 100% of cases, with 184 (92.0%) and 16 (8.0%) of patients having trace/none or mild residual mitral regurgitation, respectively. Forty-two patients (21.0%) underwent concomitant Cox-maze procedure and 25 patients (12.5%) underwent concomitant tricuspid valve repair. Thirty-day mortality rate was 0.5%, with an observed-to-expected ratio of 0.53. Two patients (1.0%) underwent re-exploration for bleeding, one had early postoperative stroke (0.5%), five developed pneumothorax (2.5%) and two required dialysis for acute renal failure (1.0%). The median length of hospital stay was four days.

Conclusions

Excellent short-term outcomes can be achieved in experienced centers for the treatment of degenerative mitral regurgitation with a totally endoscopic, robotic-assisted approach.

Parsimonious machine learning models to predict resource use in cardiac surgery across a statewide collaborative

Objective

Methods

Results

Conclusions

Early effect of the COVID-19 pandemic on the North American cardiothoracic surgery job market

Background

The present study aims to report the early effect of the coronavirus disease 2019 (COVID-19) pandemic on the cardiothoracic surgery job market in North America.

Methods

The Cardiothoracic Surgery Network (CTSNet) job market database was queried, and patterns from January to May for 2019 versus January to May 2020 were compared for trends in job postings and job seekers.

Results

Our study is comprised of 395 cardiothoracic surgery job postings, of which 98% were positions located in North America and 63% were academic. The negative impact of the pandemic on the cardiothoracic surgery job market was greatest in the cardiothoracic/cardiovascular combined subspecialty, followed by congenital and adult cardiac surgery, whereas general thoracic surgery experienced an increase in proportion of jobs available. Despite an increase in views per job posted in 2020 vs. 2019 (532 vs. 290), employer views of job seeker curriculum vitae declined over the same time period in 2020 (January, 380 views/month to May, 3 views/month) compared to 2019 (January, 100 views/month to May, 54 views/month).

Conclusions

An analysis of job postings from CTSNet suggests a decline in job availability in the North American cardiothoracic surgical job market following declaration of the pandemic with acknowledgement that there is month to month variability and a supply-demand mismatch. The COVID-19 pandemic has had an unprecedented impact on our field, and the ultimate consequences remain unknown.

Validation of the Emory Risk Score in the Transcatheter Aortic Valve Implantation Population: A Canadian Perspective

Background

Permanent pacemaker (PPM) implantation may be indicated post-transcatheter aortic valve implantation (TAVI). The Emory Risk Score (ERS) is a validated predictive risk score of the need for a PPM post-TAVI using a balloon-expandable valve. Our objectives were to determine the validity of the ERS in our local TAVI population with both balloon-expandable and self-expanding valves and to identify additional electrocardiographic (ECG) parameters predictive of the need for a PPM post-TAVI.

Methods

Retrospective chart and electronic database reviews were performed to collect demographic and procedural information. Two expert readers reviewed all ECGs. Independent factors associated with PPM implantation were examined with multivariable logistic regression via a stepwise selection process with calculation of the area under the receiver operating characteristic curve to assess model discrimination.

Results

The overall PPM implantation rate was 11.7%; rates were 9% for the Sapien 3 valves, 10% for the Evolut Pro valves, and 17% for the Evolut R valves. The ERS was found to not be predictive of need for PPM post-TAVI for the entire cohort. Right bundle branch block was the only ERS parameter independently associated with new PPM implant (8.5% vs 25%, odds ratio = 3.59, P = 0.01). No additional ECG parameters met the criteria for statistical significance.

Conclusions

The poor predictive value of the ERS in determining the need for a PPM post-TAVI in our patient population suggests that further refinement of a formula (or risk-calculator) is warranted. Identification of a precise risk-calculator is likely to facilitate patient mobilization and reduce inpatient healthcare resource utilization.

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.

Institutional Surgical Response and Associated Volume Trends Throughout the COVID-19 Pandemic and Postvaccination Recovery Period

IMPORTANCE

The COVID-19 pandemic is associated with decreased surgical procedure volumes, but existing studies have not investigated this association beyond the end of 2020, analyzed changes during the post-vaccine release period, or quantified these changes by patient acuity.

OBJECTIVE

To quantify changes in the volume of surgical procedures at a 1017-bed academic quaternary care center from January 6, 2019, to December 31, 2021.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, 129 596 surgical procedure volumes were retrospectively analyzed during 4 periods: pre-COVID-19 (January 6, 2019, to January 4, 2020), COVID-19 peak (March 15, 2020, to May 2, 2020), post-COVID-19 peak (May 3, 2020, to January 2, 2021), and post-vaccine release (January 3, 2021, to December 31, 2021). Surgery volumes were analyzed by subspecialty and case class (elective, emergent, nonurgent, urgent). Statistical analysis was by autoregressive integrated moving average modeling.

MAIN OUTCOMES AND MEASURES

The primary outcome of this study was the change in weekly surgical procedure volume across the 4 COVID-19 periods.

RESULTS

A total of 129 596 records of surgical procedures were reviewed. During the COVID-19 peak, overall weekly surgical procedure volumes (mean [SD] procedures per week, 406.00 [171.45]; 95% CI, 234.56-577.46) declined 44.6% from pre-COVID-19 levels (mean [SD] procedures per week, 732.37 [12.70]; 95% CI, 719.67-745.08; P < .001). This weekly volume decrease occurred across all surgical subspecialties. During the post-COVID peak period, overall weekly surgical volumes (mean [SD] procedures per week, 624.31 [142.45]; 95% CI, 481.85-766.76) recovered to only 85.8% of pre-COVID peak volumes (P < .001). This insufficient recovery was inconsistent across subspecialties and case classes. During the post-vaccine release period, although some subspecialties experienced recovery to pre-COVID-19 volumes, others continued to experience declines.

CONCLUSIONS AND RELEVANCE

This quaternary care institution effectively responded to the pressures of the COVID-19 pandemic by substantially decreasing surgical procedure volumes during the peak of the pandemic. However, overall surgical procedure volumes did not fully recover to pre-COVID-19 levels well into 2021, with inconsistent recovery rates across subspecialties and case classes. These declines suggest that delays in surgical procedures may result in potentially higher morbidity rates in the future. The differential recovery rates across subspecialties may inform institutional focus for future operational recovery.

2021: Perioperative and Critical Care Year in Review for the Cardiothoracic Surgery Team

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

The Effect of COVID-19 on Cardiac Surgical Volume and its Associated Costs

The COVID-19 pandemic significantly affected health care and in particular surgical volume. However, no data surrounding lost hospital revenue due to decreased cardiac surgical volume have been reported. The National Inpatient Sample database was used with decreases in cardiac surgery at a single center to generate a national estimate of decreased cardiac operative volume. Hospital charges and provided charge to cost ratios were used to create estimates of lost hospital revenue, adjusted for 2020 dollars. The COVID period was defined as January to May of 2020. A Gompertz function was used to model cardiac volume growth to pre-COVID levels. Single center cardiac case demographics were internally compared during January to May for 2019 and 2020 to create an estimate of volume reduction due to COVID. The maximum decrease in cardiac surgical volume was 28.3%. Cumulative case volume and hospital revenue loss during the COVID months as well as the recovery period totaled over 35 thousand cases and 2.5 billion dollars. Institutionally, patients during COVID months were younger, more frequently undergoing a CABG procedure, and had a longer length of stay. The pandemic caused a significant decrease in cardiac surgical volume and a subsequent decrease in hospital revenue. This data can be used to address the accumulated surgical backlog and programmatic changes for future occurrences.

COVID-lateral damage: cardiovascular manifestations of SARS-CoV-2 infection

Early in the pandemic, concern that cardiovascular effects would accompany COVID-19 was fueled by lessons from the first SARS epidemic, knowledge that the SARS-COV2 entry receptor (Angiotensin-converting enzyme 2, ACE2) is highly expressed in the heart, early reports of myocarditis, and first-hand accounts by physicians caring for those with severe COVID-19. Over 18 months, our understanding of the cardiovascular manifestations has expanded greatly, leaving more new questions than those conclusively answered. Cardiac involvement is common (∼20%) but not uniformly observed in those who require treatment in a hospitalized setting. Cardiac MRI studies raise the possibility of manifestations in those with minimal symptoms. Some appear to experience protracted cardiovascular symptoms as part of a larger syndrome of post-acute sequelae of COVID-19. Instances of vaccine induced thrombosis and myocarditis are exceedingly rare but illustrate the need to monitor the cardiovascular safety of interventions that induce inflammation. Here, we will summarize the current understanding of potential cardiovascular manifestations of SARS-COV2. To provide proper context, paradigms of cardiovascular injury due to other inflammatory processes will also be discussed. Ongoing research and a deeper understanding COVID-19 may ultimately reveal new insight into the mechanistic underpinnings of cardiovascular disease. Thus, in this time of unprecedented suffering and risk to global health, there exists the opportunity that well conducted translational research of SARS-COV2 may provide health dividends that outlast the current pandemic.

The day after tomorrow: cardiac surgery and coronavirus disease-2019

The impact of the coronavirus disease-2019 (COVID-19) pandemic forced the governments worldwide to deal with an unprecedented health crisis. The aim of this review is to summarize what happened to cardiac surgery worldwide during the first wave of this pandemic. A literature search was performed to extrapolate key concepts regarding guidelines and reorganization of cardiac surgery wards during COVID-19. Supporting literature was also included to discuss the hot topics related to COVID-19 and cardiac surgery. Hence, both official documents from national scientific societies and single- or multiple-center experiences during the pandemics are reviewed and discussed. In Italy, the first western country hit by the pandemic, two different models were proposed to cope with the need for ICU/ward beds and to reallocate cardiac surgical services: Hub-and-Spoke system ('Hubs', dedicated to perform urgent and nondeferrable surgery, and 'Spokes', turned into COVID centers) and/or a progressive reduction in surgical activity. Worldwide, several guidelines/consensus statements were published, suggesting how to deal with the outbreak. Two different approaches for stratifying surgical indications were proposed: dynamic, based on the number of hospitalized COVID-19 patients; static, based only on the severity of the cardiovascular disease. Moreover, the importance of personal protective equipment was stressed. Several measures should have been adopted to deal with an unprecedented need for healthcare resources allocation to care for COVID-19 patients, putting the healthcare systems under serious stress. Cardiac surgery has, as have most surgical activities, been asked to reduce its own activity, giving priority to emergency and nondeferrable cases.

Derivation and validation of a clinical risk score to predict death among patients awaiting cardiac surgery in Ontario, Canada: a population-based study

BACKGROUND

Surgical delay may result in unintended harm to patients needing cardiac surgery, who are at risk for death if their condition is left untreated. Our objective was to derive and internally validate a clinical risk score to predict death among patients awaiting major cardiac surgery.

METHODS

We used the CorHealth Ontario Registry and linked ICES health administrative databases with information on all Ontario residents to identify patients aged 18 years or more who were referred for isolated coronary artery bypass grafting (CABG), valvular procedures, combined CABG-valvular procedures or thoracic aorta procedures between Oct. 1, 2008, and Sept. 30, 2019. We used a hybrid modelling approach with the random forest method for initial variable selection, followed by backward stepwise logistic regression modelling for clinical interpretability and parsimony. We internally validated the logistic regression model, termed the CardiOttawa Waitlist Mortality Score, using 200 bootstraps.

RESULTS

Of the 112 266 patients referred for cardiac surgery, 269 (0.2%) died while awaiting surgery (118/72 366 [0.2%] isolated CABG, 81/24 461 [0.3%] valvular procedures, 63/12 046 [0.5%] combined CABG-valvular procedures and 7/3393 [0.2%] thoracic aorta procedures). Age, sex, surgery type, left main stenosis, Canadian Cardiovascular Society classification, left ventricular ejection fraction, heart failure, atrial fibrillation, dialysis, psychosis and operative priority were predictors of waitlist mortality. The model discriminated (C-statistic 0.76 [optimism-corrected 0.73]). It calibrated well in the overall cohort (Hosmer-Lemeshow p = 0.2) and across surgery types.

INTERPRETATION

The CardiOttawa Waitlist Mortality Score is a simple clinical risk model that predicts the likelihood of death while awaiting cardiac surgery. It has the potential to provide data-driven decision support for managing access to cardiac care and preserve system capacity during the COVID-19 pandemic, the recovery period and beyond.

COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The primary aim was to compare length of stay (LOS) and discharge disposition of adult spinal deformity (ASD) patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, reoperations, readmissions, and unplanned emergency department (ED) visits.

SUMMARY OF BACKGROUND DATA

ASD patients often require extended LOS and non-routine discharge. Given resource limitations during the Coronavirus Disease 2019 (COVID-19) pandemic and caution regarding hospital stays, surgeons modified standard postoperative protocols to minimize patient exposure.

METHODS

We identified all patients who underwent elective thoracolumbar ASD surgery with more than or equal to five levels fusion at a tertiary care center during two distinct time intervals: July to December 2019 (Pre-COVID, N = 60) and July to December 2020 (During-COVID, N = 57). Outcome measures included LOS and discharge disposition (home vs. non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors.

RESULTS

Patients who underwent ASD surgery during the pandemic were younger (61 vs. 67 yrs) and had longer fusion constructs (nine vs. eight levels) compared with before the pandemic (P < 0.05 for both). On bivariate analysis, patients undergoing surgery during the pandemic had shorter LOS (6 vs. 9 days) and were more likely to be discharged home (70% vs. 28%) (P < 0.05 for both). After controlling for age and levels fused on multivariable regression, patients who had surgery during the pandemic had shorter LOS (IRR = 0.83, P = 0.015) and greater odds of home discharge (odds ratios [OR] = 7.2, P < 0.001). Notably, there were no differences in major complications, reoperations, readmissions, or ED visits between the two groups.

CONCLUSION

During the COVID-19 pandemic, LOS for patients undergoing thoracolumbar ASD surgery decreased, and more patients were discharged home without adversely affecting complication or readmission rates. Lessons learned during the pandemic may help improve resource utilization without negatively influencing short-term outcomes.Level of Evidence: 3.

Comparative Trends in Ischemic Heart Disease Admissions, Presentation and Outcomes Due to the COVID-19 Pandemic: First Insights From a Tertiary Medical Center in Pakistan

Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p<0.001), month of admission (p<0.001), proportions ACS (p<0.001), non-ST-elevation-myocardial-infarction (NSTEMI; p<0.001), unstable angina (p=0.025) and medical management (p=0.002) showed significant differences between the two groups, with a sharp decline in the during-COVID group. Monthly trend analysis of ACS patients showed the most significant differences in admissions (p=0.001), geographic region (intra-district vs intracity vs outside city) (p<0.001), time of admission (p=0.038), NSTEMI (p=0.002) and medical management (p=0.001). Conclusion These data showcase stark declines in ACS admissions, diagnostic procedures (angiography) and revascularization interventions (angioplasty and coronary artery bypass graft surgery, CABG) in a developing country where resources and research are already inadequate. This study paves the way for further investigations downstream on the short- and long-term consequences of untreated IHD and reluctance in health-seeking behaviour.

Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist

BACKGROUND

Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery.

METHODS

We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection.

RESULTS

Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points.

INTERPRETATION

We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.

Perioperative Coronavirus Vaccination - Timing and Implications: A Guidance Document

Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.

The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717 103 Patients

Background

COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels.

Methods

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from January 1, 2018, to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020, to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality.

Results

The study analyzed 717 103 adult cardiac surgery patients and more than 20 million COVID-19 patients. Nationally, there was a 52.7% reduction in adult cardiac surgery volume and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19–associated deficit of cardiac surgery patients.

Conclusions

This large analysis of COVID-19–related impact on adult cardiac surgery volume, trends, and outcomes found that during the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

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.

["Prioritization and triage" in the context of cardiovascular diseases : Rational organization of safe care during and outside the corona pandemic]

Since the beginning of 2020 the coronavirus disease 2019 (COVID-19) pandemic has extensively impacted medical care in Germany and worldwide. Germany is currently facing the so-called third wave of the COVID-19 pandemic. This is exacerbated by emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mutants with increased virus transmission and severe courses of disease. Rising numbers of SARS-CoV‑2 infections translate into an increasing number of severe COVID-19 cases requiring intensive care, which interacts with limited structural and personnel resources for COVID-19 and non-COVID-19 critically ill patients. Therefore, prioritization and triage for critically ill patients with allocation of intensive care capacities becomes necessary, as with all situations with higher strain on capacities. Both strategies are meaningful forms of organization and are not to be equated with a collapse of medical care. Cardiovascular comorbidities and cardiac involvement in COVID-19 are of particular importance for disease severity and the clinical course. In addition to the medical care of patients with SARS-CoV‑2 infections due to the pandemic, other patients with acute sometimes life-threatening diseases must also continue to receive high-quality treatment. This article provides a current overview of proposed restructuring measures in German hospitals as well as the accompanying triage and prioritization algorithms. Moreover, it is necessary to adapt existing treatment algorithms to the pandemic situation. Due their special importance this is sketched using cardiovascular diseases as an example.

The impact of coronavirus 2019 on general surgery residency: A national survey of program directors

Background

Coronavirus disease 2019 (COVID-19) has had a widespread impact on graduate medical education. This survey aims to assess how general surgery residency programs adapted to the initial wave of the COVID-19 pandemic in the United States (US).

Materials and methods

General surgery program directors (PDs) in the US were invited to partake in a 16-question survey between April 17 and May 1, 2020. The survey included questions about basic program information, clinical practice changes, changes to education structure, surgery resident clinical duties, and perceived impact on resident operative experience and future career choices.

Results

Forty-eight PDs completed the survey in the designated two-week period. Almost all (44/48, 91.7%) programs changed their didactic education to an online video conference-based format. Thirteen programs (27.1%) decreased the amount/frequency of formal education, and 13 (27.1%) reported canceling didactic education for some period of time. The majority of PDs (26/48, 54.2%) felt these changes had no impact on resident didactic participation, 14 (29.2%) reported an increase in participation, and 8 (16.7%) reported decreased participation. Ten programs (20.8%) redeployed residents to non-surgical services at the time of this survey, 30 (62.5%) have not redeployed residents but plan to if needed, and 8 (16.7%) did not have any plans to redeploy residents.

Conclusions

The outbreak of COVID-19 has required general surgery residency PDs to change numerous aspects of resident education and clinical roles. Future inquiry is needed to assess if these changes lead to appreciable differences in resident preparedness and career selection.

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At the time of this survey, all institutions had cancelled elect cases.

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Over 90% of program directors implemented video-based didactic education.

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Alternating blocks of on- and off-service was the most common schedule change.

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Residents participated in “line” or “procedural” teams in 14.6% of programs.

Impact of COVID-19 Pandemic in a Brazilian High-Volume Aortic Center

Introduction

The coronavirus disease 2019 (COVID-19) pandemic brought an unprecedented lack of control of what was to come. The intent of this document is to provide a balance of how much was ceased to be done for patients with aortic disease, to assess the mortality of these patients, and to show what happened to those who became COVID-19 positive during their hospitalization.

Methods

From April 1st to July 31st 2020, the worst period of the pandemic in São Paulo, Brazil, the Institute’s aortic surgical patients operated on were evaluated and those were compared with patients operated during the same period in 2019.

Results

In 2019, 88 surgeries were performed; most of them were elective (66 [75%]), 10 were urgent, and 12 were emergency surgeries. In 2020, during the COVID-19 pandemic, we operated on only 31 patients, being 74.2% non-elective surgeries (P<0,001). There was a higher mortality for patients operated on during the pandemic surge of COVID-19 (P<0,001), but it was not specifically related to infected patients.

Conclusion

The COVID-19 pandemic had an impact on surgical volume and outcome of patients with aortic disease, although it did not directly increase mortality.

Artificial intelligence and cardiac surgery during COVID-19 era

The coronavirus disease 2019 (COVID-19) pandemic has increased the burden on hospital staff world-wide. Through the redistribution of scarce resources to these high-priority cases, the cardiac sector has fallen behind. In efforts to reduce transmission, reduction in direct patient-physician contact has led to a backlog of cardiac cases. However, this accumulation of postponed or cancelled nonurgent cardiac care seems to be resolvable with the assistance of technology. From telemedicine to artificial intelligence (AI), technology has transformed healthcare systems nationwide. Telemedicine enables patient monitoring from a distance, while AI unveils a whole new realm of possibilities in clinical practice, examples include: traditional systems replacement with more efficient and accurate processing machines; automation of clerical process; and triage assistance through risk predictions. These possibilities are driven by deep and machine learning. The two subsets of AI are explored and limitations regarding "big data" are discussed. The aims of this review are to explore AI: the advancements in methodology; current integration in cardiac surgery or other clinical scenarios; and potential future roles, which are innately nearing as the COVID-19 era urges alternative approaches for care.

Impact of early Coronavirus Disease 2019 pandemic on pediatric cardiac surgery in China

OBJECTIVE

This study aimed to provide an insight into the impact of the early outbreak of the novel Coronavirus Disease 2019 on the care management for patients with congenital heart disease.

METHODS

This study respectively enrolled a cohort of surgical patients who underwent surgery in 2018 (group I), 2019 (group II), and 2020 (group III) and a cohort of follow-up patients who had follow-up in 2017 (group A), 2018 (group B), and 2019 (group C) in 13 children hospitals.

RESULTS

During the Coronavirus Disease 2019 era, there was a significant decrease in total surgical volume and a change in case mix in terms of an increase in the proportion of emergency operations. Decrease in migration scale index was correlated to the decrease in both surgical volume (r = 0.64, P = .02) and outpatient visit volume (r = 0.61, P = .03). There was a significantly higher proportion of patients who had follow-up through the internet or phone in group C (26.4% vs 9.6% in group B and 8.9% in group A; P < .0001). There was no statistical difference in death or rehospitalization among the 3 follow-up groups (P = .49). There was higher parents' anxiety score (P < .0001) and more use of telemedicine (P = .004) in group C compared with groups A and B.

CONCLUSIONS

The Coronavirus Disease 2019 pandemic has resulted in a considerable decrease in total surgical volume and a change of case mix, which seems to be related to the strict traffic ban. Follow-up through the online medical service appears to be an effective alternative to the conventional method.

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.