key: cord-345745-t36jbg14
authors: Murashita, Takashi
title: Commentary: The Era of Great Uncertainty
date: 2020-06-27
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.06.054
sha: 
doc_id: 345745
cord_uid: t36jbg14

nan

In the era of COVID-19 pandemic, cardiac surgeons need to be aware that undiagnosed infection can cause unexpected catastrophic complications after urgent or emergent operations.

Takashi Murashita, MD

The current pandemic of coronavirus disease 2019 (COVID-19) has made a significant impact on our practice of cardiothoracic surgery. Due to the increasing burden of the clinical resources and concern for nosocomial spread, the number of cardiac surgery cases has dramatically decreased. One study showed that a 54% drop in cardiac surgical volume was observed after restrictions were implemented (1). The Society of Thoracic Surgeons recently published a patient triage guidance statement during the COVID-19 pandemic (2) . All non-urgent cases are recommended to be deferred, whereas care providers need to contemplate a balance of risk of having the patients' treatment delayed vs increasing the risk of acquiring nosocomial COVID-19.

Since each hospital is encouraged to adopt a mechanism by which patients can be screened for COVID-19 infection perioperatively, many centers have started screening all patients undergoing elective surgery. However, in urgent or emergent situations such as type A aortic dissection, acute coronary syndromes, and acute valvular endocarditis, patients may need to be taken to the operating room without being tested for COVID-19 infection.

In the current issue of The Journal of Thoracic and Cardiovascular Surgery, Salna and colleagues reported a case of urgent coronary artery bypass grafting (CABG) whose postoperative course was complicated with severe acute respiratory distress syndrome (ARDS) caused by COVID-19 infection (3). This is a case report from New York, which was hit drastically by the COVID-19 outrage. The patient, who recently returned from Manilla and Hong Kong, presented with acute coronary syndrome, and was found to have triple vessel coronary artery disease with reduced left ventricular function. Preoperatively, the patient did not show any sign of respiratory infection, such as fever, cough, or dyspnea. The patient underwent an urgent three-vessel CABG. On the following day of surgery, the patient developed fever, and his oxygenation progressively worsened with diffuse pulmonary infiltrates on x-ray. He was found to be COVID-19 positive. His clinical course was also complicated with ST changes on electrocardiogram, elevated cardiac enzymes, thromboembolic events in the brain and extremities, septic shock, and disseminated intravascular coagulation. Due to non-recoverable neurological status and inability to wean from pressors or ventilator, his care was withdrawn, and the patient expired. Considering the rapid deterioration of the clinical condition, the patient was most likely infected with COVID-19 prior to admission. The screening of COVID-19 was not done due to an urgent situation.

It has been shown that there are a variety of manifestations of COVID-19, but the effect of the virus on cardiovascular system is still being defined (4, 5) There is also little data about the impact of COVID-19 infection on the clinical outcomes of cardiac surgery. A similar case to the current article was reported from United Kingdom (6) . A 63-year-old male underwent an elective three-vessel CABG and tricuspid valve repair, and his initial postoperative course was uneventful. On postoperative day 1, he developed severe hypoxia with bilateral consolidation on x-ray. COVID-19 pneumonia was diagnosed by bronchial alveolar lavage. His respiratory condition continued to decline, and the patient expired. The patient did not have any sign of preoperative respiratory infection, therefore, the COVID-19 screening had not been performed.

In addition to ARDS, COVID-19 is known to be associated with coagulation abnormalities and thrombosis (7) . In this article of Salna and colleagues, the patient's postoperative course was adversely affected by COVID-19 induced hypercoagulability. Due to the high prevalence of coagulopathy and thrombosis in COVID-19, it is suggested that D-dimers and fibrinogen levels are frequently monitored, and all hospitalized patients with COVID-19 undergo thromboembolism prophylaxis (8) .

As Salna and colleagues suggested, emergent cardiac surgery cannot stop in the wake of a global pandemic. In urgent or emergent situations, we may not have time to check the patients' COVID-19 status preoperatively. Therefore, in this era of great uncertainty, all cardiac surgeons might encounter the same situation, where unpredicted complications occur following wellperformed operations. We need to be aware that undiagnosed COVID-19 might be hidden, especially in urgent or emergent cases.

The surge after the surge: cardiac surgery post-COVID-19

Society of Thoracic Surgeons COVID-19 Taskforce and the Workforce for Adult Cardiac and Vascular Surgery

A case of COVID-19 presenting after coronary artery bypass grafting

Potential Effects of Coronaviruses on the Cardiovascular System: A Review

Association of Coronavirus Disease 2019 (COVID-19) with Myocardial Injury and Mortality

A case of postoperative Covid-19 infection after cardiac surgery: Lessons learned

Coagulation abnormalities and thrombosis in patients with COVID-19

Coagulopathy of Coronavirus Disease