key: cord-290731-xp7pgbkd
authors: Balmforth, D.; Yates, M.; Lau, K.; Hussain, A.; Lopez-Marco, A.; Edmondson, S.; Oo, A.; Uppal, R.; Sepehripour, A.; Lall, K.; Roberts, N.; Salvo, C Di; Kolvekar, S.; Wong, K.; Ambekar, S.; Sheikh, A.; Adams, B.; Yap, J.; Lawrence, D.; Awad, W.; Shipolini, A.; Rathwell, C.; Rahnavardi, Mohamed; Stamenkovic, Steven; Waller, David; Wilson, Henrietta; Al-Sahaf, May
title: Cardiothoracic Surgery in the Midst of a Pandemic: Operative outcomes and maintaining a COVID-19-free environment.
date: 2020-09-23
journal: nan
DOI: 10.1016/j.xjon.2020.09.003
sha: 
doc_id: 290731
cord_uid: xp7pgbkd

Objective In the United Kingdom, the COVID-19 pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. Methods Data on all patients undergoing cardiothoracic surgery at a single tertiary referral centre in London was prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19 free environment including the pre-operative screening of all patients, the use of full personal protective equipment in areas with aerosol generating procedures, and separate treatment pathways for patients with and without the virus Results A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The pre-operative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on pre-operative screening tested positive post-operatively. However, one thoracic patient tested positive on intra-operative broncho-alveolar lavage. Conclusion Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of post-operative COVID-19 infection.

The COVID-19 pandemic presents unique challenges to the provision of cardiothoracic 85 surgery globally. In response to the high demand for ventilators and intensive care unit (ITU) 86 beds created by the virus, the United Kingdom ceased all elective surgical procedures. 87 However, there remains a need to provide cardiac surgery for urgent and emergency cases as 88 well as time-critical thoracic cancer surgery. In London, where the prevalence of COVID -19 89 cases in the UK was highest, we met this need by introducing a strict protocol to maintain a 90 COVID-free environment. This was mandated by early reports of high mortality associated 91 with developing COVID-19 post-operatively (1, 2). The aim of this paper is to describe our early experience of operating during the pandemic. 103 We report our ability to maintain a COVID-19 free environment and the operative outcomes 104 during the first 7 weeks of lockdown. The different patient pathways for outpatients, inter-105 hospital transfers and emergency surgery are discussed. All patients undergoing major cardiac or thoracic surgery between the 26 rd March 2020 and 112 the 10 th May 2020 at a single institution were prospectively entered into a database. In 113 addition to the routine collection of pre-operative demographics, data was collected on the 114 results of COVID-19 screening tests both pre-and post-operatively, as well as patient 115 outcomes including in-hospital mortality and discharge destination. All data was collected as 116 part of an ongoing audit of surgical provision in the COVID-19 pandemic and anonymised 117 prior to analysis. Approval was granted by the local institutional review board.

Patients undergoing cardiac or thoracic surgery followed tailored pathways aimed at 120 maintaining a COVID-free environment in dedicated intensive therapy units (ITU) and 121 wards. A detailed overview of our protocol has been published (6) and a simplified version of 122 the patient pathways and screening protocols is shown in figure 1. In brief, all patients 123 requiring inter-hospital transfer for urgent or emergency surgery were screened at the time of 124 referral with a screening questionnaire and upper respiratory tract swab for COVID-19 RNA.

If patients were asymptomatic and swab negative, they were transferred to our institution and 126 kept in isolation until a second swab confirmed they were COVID-19 negative. Following Patients admitted from home for surgery were advised to self-isolate at home for two weeks 136 prior to being admitted to a side room on a dedicated COVID-free ward. They then 137 underwent the same screening protocol as described above. Patients who tested positive in 138 this cohort were discharged home and their operation was postponed for at least 30 days to 139 allow lung recovery. An overview of the baseline characteristics, screening test results and operative outcomes for 167 both cardiac and thoracic surgery is shown in Table 1 . During the study period, 76 patients were admitted for cardiac surgery. Of these, 56 (73.7%) 172 were inpatients requiring urgent surgery, 16 (21%) were emergency admissions, and just 4 173 (5.3%) were elective patients admitted from home. 67 (88%). patients underwent surgery as 174 planned. Of the remaining 9 patients, 3 were emergencies who died prior to reaching the 175 operating theatre, 1 was discharged home as they were not deemed in need of surgery during 176 their admission, and 5 tested positive for COVID-19 and were discharged home to recover.

The types of operation performed on the 67 patients who had surgery is shown in figure 1A .

Of the 76 patients planned for cardiac surgery 61 (80.2%) were discharged home. The median 180 post-operative stay was 6 days. 9 patients (11.8%) died during their admission with an 181 operative mortality of 6/67 (9%). This is comparable with the mean EuroSCORE II for the 182 operated population of 6.3%. Four of these mortalities were emergency patients; 3 type A available to the department due to staff and intensive care beds being reallocated to the 283 treatment of COVID-19. As such, some case selection had to be undertaken to prioritise these 284 reduced resources. Lower risk patients where it was thought safe to defer surgery were 285 discharged home, resulting in a higher risk operative cohort than prior to the pandemic.

Despite the high-risk nature of the patient cohorts in this study, we did not observe 287 significantly higher death rates than expected. The cardiac operative mortality of 9% is not 288 significantly higher than the 4% mortality observed in the 149 urgent and emergency patients 289 operated between March and April 2019 (p=0.07) and compares to a predicated mortality of 290 6.3% from the cohort's predicted mean EuroSCORE II. Of the 6 cardiac patients 4 were 291 emergency operations and 2 were high risk urgent operations (leaking descending thoracic 292 aneurysm and infective endocarditis). Our reported cardiac mortality should be viewed in the 293 context that the operated cohort was higher risk than our usual practice. During the study 294 period the agreed criteria for conventional surgical intervention for ischaemic heart disease 295 was modified with a bias towards PCI and early discharge to a safe environment. This was 296 agreed nationally between the governing cardiac surgical and interventional cardiology 297 J o u r n a l P r e -p r o o f societies. As such the threshold for patients requiring inpatient surgery during the pandemic 298 was raised due to the additional risk associated with remaining in hospital.

In addition to the cardiac surgical results, we observed excellent operative mortality of just 301 1.4% in 73 thoracic operations. These data confirm that our ability to perform major cardiac 302 and thoracic procedures safely has not been diminished by the pandemic. In the cardiac cohort the number of patients who were positive on pre-operative screening 347 was higher than the thoracic cohort [15/76 (19.7%) Vs 3/76 (3.9%)]. One explanation is that 348 the cardiac patients were predominantly acute admissions from other hospitals whereas the 349 thoracic patients had been isolating at home for a minimum of 2 weeks prior to admission. 350 Recent evidence suggests that the incidence of COVID-19 infection both amongst healthcare 351 J o u r n a l P r e -p r o o f workers and in the community has reduced significantly since the onset of lockdown (9).

This, together with the low rate of COVID-19 positivity in the elective cohorts, prompted a 353 decision to offer cardiac surgery to patients at home who were known to be developing 354 worsening symptoms. As the pandemic progressed, 4 patients have been admitted from home 355 for cardiac surgery after 2 weeks of isolation. As the prevalence of COVID-19 falls 356 operations will resume for the backlog of patients for whom surgery has been deferred. When 357 considering operating on this lower risk group of patients it is important to be able to 358 maintain a COVID-19-free environment as well as no additional operative mortality. We plan 359 to use the pathways described in this report to progressively increase the volume of patients 360 undergoing elective cardiac and thoracic surgery. We believe that the success of this pathway 361 has provided the route back to full capacity operating in the pandemic. 

Clinical characteristics and outcomes of 374 patients undergoing surgeries during the incubation period of COVID-19 infection

Perioperative Period of Lung Resection: A Brief Report From a Single Thoracic Surgery Department in 378

People's Republic of China

Adult Cardiac Surgery 380 and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies are Necessary in the 381 Operating Room and Surgical Recovery

Adult cardiac surgery 383 during the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement

Canada During the COVID-19 Pandemic: A Guidance Statement From the Canadian Society of Cardiac 386 Surgeons

London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic

Ethnicity and 391 outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort 392 study

Detection of SARS-CoV-2 in Different Types of 394 Clinical Specimens

COVID-19: PCR 396 screening of asymptomatic health-care workers at London hospital