key: cord-291686-kgewmqg5 authors: Patel, Surendra; Kaushik, Atul; Sharma, Alok Kumar title: Prioritizing cardiovascular surgical care in COVID‐19 pandemic: Shall we operate or defer? date: 2020-07-15 journal: J Card Surg DOI: 10.1111/jocs.14864 sha: doc_id: 291686 cord_uid: kgewmqg5 BACKGROUND: The coronavirus disease (COVID‐19) has affected a large population across the world. Patients with cardiovascular disease have increased morbidity and mortality due to coronavirus disease. The burden over the health care system has to be reduced in this global pandemic to provide optimal care of patients with COVID‐19, as well not compromising those who are in need of emergent cardiovascular care. METHODS: There is a very limited data published defining which cardiovascular procedures are to be performed or to be deferred in the COVID‐19 pandemic. In this article, we have reviewed a few published guidelines regarding cardiovascular surgery in COVID‐19 pandemics. CONCLUSION: After reviewing a few available guidelines regarding cardiovascular surgery in COVID‐19, we conclude to perform only those surgeries which cannot be deferred to a certain period of time, to reduce the burden of the health care system of the country, provide optimal care to patients with COVID‐19, and to protect health care workers and cardiovascular patients from COVID‐19. Severe acute respiratory syndrome due to coronavirus is also known as SARS-CoV-2 or coronavirus disease 2019 (COVID-19), has been first reported from Wuhan, China in December 2019. 1 The cases of COVID-19 increased rapidly across the world and affects almost all countries. On 11th March 2020, the World Health Organization has declared the COVID-19 as global pandemic. Approximately 80% of the patients infected with COVID-19 are asymptomatic or mildly symptomatic and 20% of the patients are symptomatic requires the use of health care facility. The case fatality rate although variable is estimated at around 0.5% to 3%. 2 In this situation of the pandemic, the aim of all the health care systems across the world is to provide optimum care and treatment to suspected or confirmed case of COVID-19. Moreover there is lack of sufficient data regarding impact of COVID-19 on post operative outcomes in patients who were infected with novel coronavirus and underwent cardiac and thoracic procedures. Peng et al 3 reported that patient who underwent thoracic surgery at the time of pandemic and later found to be affected with the novel coronavirus had greater than anticipated incidence of severe illness as well as case fatality rate, thus emphasizing the importance of correct triage and prioritizing cases to be considered for cardiac and thoracic surgery. The pandemic since its outbreak has increased in global number of cases with only few countries have controlled its impact on health and economic resources while most of the countries are still facing an unprecedented challenge in terms of containing its spread and proper allocation of health care resources to those who are affected. To provide adequate and guideline-directed treatment to those requiring cardiovascular interventions and surgeries becomes challenging when the capacity tends to get overwhelmed in such situations, hence for the fair allocation of the medical resources, guidelines have to be made and prioritization should be done. 4 There is a very limited data published defining which cardiovascular procedures are to be performed or to be deferred in the COVID-19 pandemic. In this article, we have reviewed guidelines of few centers regarding cardiovascular surgery in COVID-19 pandemic to effectively triage and plan these surgeries and allocating resources to those who are in utmost need. Cardiovascular patients have a greater risk of acquiring COVID-19 infection, with morbidity and mortality much more in these patients in comparison to healthy individuals. 5 showed that around 48% of the patients had comorbidities, out of this hypertension was most common (30%), followed by diabetes mellitus (19%) and CAD (8%). Acute heart failure was present in 23% of patients, the major precipitating factors were acute myocarditis, acute coronary events and cardiac arrhythmias. The angiotensin-converting enzyme 2 (ACE-2) receptor has been identified as a receptor for SARS-CoV-2 invasion into the cells, and myocytes have abundant ACE-2 receptors that increase the risk of injury to myocytes and precipitating myocarditis, acute coronary events, arrhythmias, and acute heart failure. 7 We as cardiovascular surgeons have to protect the cardiovascular Canadian Society of Cardiac Surgeons released a guidance statement in which they defined three stages of triage of cardiac surgical procedures, to be modified on the local context, infrastructure and capacity of the hospital. 10 Stage 1 reduces services to 0% to 30%, stage 2 to 30% to 50%, and stage 3 to more than 50%. Each stage is further subdivided into two, essential services, and deferred cases. (2) Use of full personal protective equipment should to be adopted in every case by the theater team regardless of the patient's COVID-19 status. (3) Risk of COVID-19 exposure for patients undergoing heart surgery should be considered moderate to high and likely to increase mortality if it occurs. (4) Cardiac procedures should be decided based on ad-hoc multi disciplinary team for every patient. Although there was not a strong consensus but most of the surgeons (more than 50%) agreed upon: (1) Patients who tested positive for COVID-19 before salvage surgery should be considered for surgery only if they have no symptoms of infection and have best chances of survival. (2) Aortic and mitral valve surgery could be considered only in selected cases. (3) CABG should be considered only in selective cases. Mavioglu et al 13 reported article on perioperative planning for cardiovascular operations in the COVID-19 pandemic in the Turkish Journal of Thoracic and Cardiovascular Journal. They have defined a total four level of priority (LoP) for cardiovascular procedures to be done in COVID-19 pandemic. LoP I is elective cases, LoP II is urgent cases, LoP III is emergent cases, and LoP-IV is salvage cases ( Table 1 ). The LoP I should be postponed as much as possible, and LoP II-IV should be operated with protective measures. Patients with COVID-19 has increased risk of venous thromboembolism. COVID-19 pneumonia is associated with abnormal coagulation and there is an increased risk of disseminated intravascular coagulation in critically ill patients and has increased morbidity and mortality. 14 American college of surgeons has defined triage guidelines for vascular surgery patients, 8 and have provided guidelines regarding whether to postpone or not, vascular surgical procedures including, ascending aortic aneurysm, peripheral aneurysms, aortic dissection, mesenteric ischemia, peripheral vascular disease, trauma, venous thromboembolism, and amputation of limbs (Table 2) . Critically ill patients with COVID-19 are at increased risk of both thrombosis and bleeding. In these patients, Pauda predilection score may be more helpful than just clinical assessment for risk of venous thromboembolism. 15 with COVID-19. Critically ill patients with COVID-19 will be benefited by the use of low molecular weight or unfractionated heparin. 16 9 | AUTHOR'S VIEWPOINT • All patients with stable, non-ruptured aortic aneurysms irrespective of the size of the aneurysm. • All patients with chronic limb and mesenteric ischemia. • Asymptomatic patients with blocked prosthetic grafts and stents. (2) Perform surgeries in which outcomes will be significantly altered if the procedure is deferred for a certain period of time. These procedures should be done using standard universal precautions and prior COVID testing should be done as per individual institutional policy. • CAD: Perform surgeries for the critical left main disease, severe TVD with hemodynamic instability, and or having a ventricular arrhythmia, mechanical complications of acute myocardial infraction, such as ventricular septal rupture, cardiac free wall rupture and acute ischemic mitral regurgitation. Acute coronary syndrome with anatomy not suitable for percutaneous coronary interventions. • Valvular heart surgery: Patients with valvular heart disease with heart failure not responding to medical management. Acute mitral regurgitation, acute aortic regurgitation, symptomatic critical aortic stenosis, obstructive prosthetic valve thrombosis, infective endocarditis (native or prosthetic) not responding to maximal medical management. • Congenital heart disease: Patients with a cyanotic spell, or in heart failure not responding to medical management. • this may cause significant alteration in the outcome of the disease. These recommendations should be considered on case to case basis and need regular updates according to individual institutional policy or guidelines released by the national or international society of cardiovascular surgeons. 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The authors declare that there are no conflict of interests. http://orcid.org/0000-0003-1474-6738Atul Kaushik https://orcid.org/0000-0001-9842-7245