key: cord-0048419-ldi18rf6 authors: Iribarne, Alexander; Thourani, Vinod H.; Cleveland, Joseph C.; Malaisrie, Sukit Christopher; Romano, Matthew A.; Moon, Marc R.; Ramakrishna, Harish; Mewhort, Holly E. M.; Halkos, Michael; Sultan, Ibrahim; Kindler, Christine; Firstenberg, Michael S.; Dayan, Victor; Kasirajan, Vigneshwar; Salerno, Chris; Phillips, Alistair title: Cardiac surgery considerations and lessons learned during the COVID‐19 pandemic date: 2020-07-15 journal: J Card Surg DOI: 10.1111/jocs.14798 sha: e608a036d7de8e55ba6f6d1de3e153c7d5122d22 doc_id: 48419 cord_uid: ldi18rf6 The COVID‐19 pandemic has transformed cardiac surgical practices. Limitations in intensive care resources and personal protective equipment have required many practices throughout the globe to pause elective operations and now slowly resume operations. However, much of cardiac surgery is not elective and patients continue to require surgery on an urgent or emergent basis during the pandemic. This continued need for providing surgical services has introduced several unique considerations ranging from how to prioritize surgery, how to ensure safety for cardiac surgical teams, and how best to resume elective operations to ensure the safety of patients. Additionally, the COVID‐19 pandemic has required a careful analysis of how best to carry out heart transplantation, extra‐corporeal membrane oxygenation, and congenital heart surgery. In this review, we present the many areas of multidisciplinary consideration, and the lessons learned that have allowed us to carry out cardiac surgery with excellence during the COVID‐19 pandemic. As various states experience plateaus, declines, and rises in COVID‐19 cases, these considerations are particularly important for cardiac surgical programs throughout the globe. The COVID-19 pandemic has transformed cardiac surgical practices throughout the globe. 1 Although many elective operations were delayed, surgeons were forced to balance the ongoing need of providing urgent and emergent surgical care with the new realities of limited resources. However, cardiac surgery is a resource-intensive specialty where excellence requires multidisciplinary coordination between cardiology, surgery, anesthesia, critical care, perfusionists, and nursing. Moreover, cardiac surgery patients transition through different phases of care (preoperative, operative, intensive care, step-down, and cardiac rehabilitation), which creates unique challenges for preventing disease transmission for patients and their care teams. In this review, we discuss the challenges that COVID-19 has created for cardiac surgery, the solutions hospitals have developed to maintain safety and excellence during the pandemic, and the strategies surgical teams have employed as we re-open cardiac surgical programs. Although a limited amount of cardiac surgery continued during the peak of the pandemic, critical attention to case selection and triage are now standard practice. Deferral of elective cardiac surgery and now subsequent rescheduling to address backlogs and waiting lists has become a reality. The American College of Surgeons (ACS) released recommendations for surgical management of elective operations during the COVID-19 pandemic. 2 The ACS scale categorized elective procedures into three tiers: Tier 1 (low acuity), Tier 2 (intermediate acuity), and Tier 3 (high acuity) with subcategories A and B in each tier differentiated as a healthy or nonhealthy patient, respectively. The scale was developed for multiple subspecialties, but was less pertinent to cardiac surgery because the scale was limited to elective cases and did not account for urgent and emergent cases. We developed an expert consensus document to further characterize case prioritization in cardiac surgery in the safest manner, while providing appropriate patient education of the continuously evolving situation unique to local state epidemiology. A Cardiac Surgery Acuity Scale is shown in Table 1 and builds upon the widely accepted ACS Elective Surgery Acuity Scale by accounting for inpatients who require urgent or emergent treatment. In addition to Tier 1 to 3 elective interventions, the Cardiac Surgery Acuity Scale includes Tier 4a: urgent surgery required to permit safe hospital discharge, Tier 4b: urgent surgery required within 24 to 48 hours to prevent clinical deterioration, and Tier 5: emergent surgery required to prevent immediate death. Medical therapy while waiting for cardiac surgery includes prudent monitoring of symptom progression and timely cardiac imaging by taking advantage of modern virtual technology. Telehealth via phone or videoconferencing has rapidly expanded as an alternative to in-person outpatient clinic visits. Moreover, advances in digital health technology provide opportunities for remote monitoring of physiologic parameters. Leveraging the convenience and social distancing provided by virtual clinic visits, telehealth allows the cardiac surgeon and healthcare team to actively monitor the condition of patients whose cardiac surgery has been postponed. New onset or progression of symptoms increases the surgical acuity of patients waiting for elective surgery and in some cases requires hospitalization. Sudden cardiac death and unplanned hospital admissions for clinical deterioration may be avoided by aggressive monitoring of symptoms and interval cardiac imaging to assess for disease progression. In circumstances where healthcare systems face significant shortages of critical care beds, a situation that has fortunately become less common, there may be unique situations where certain inpatients may benefit from either: (a) a temporizing catheter-based therapy as an alternative to cardiac surgery for urgent (Tier 4) and emergent (Tier 5) pathologies to minimize hospital stay and/or (b) transfer to a center where the system is less stressed to conserve resources. The American College of Cardiology (ACC) Interventional Cardiology Council has addressed the management of interventional procedures including coronary and structural heart disease 3,4 and addressed the concern for periprocedural COVID-19 exposure. Endovascular options for thoracoabdominal aortic disease similarly expedite patient recovery and should be given consideration during this time of limited critical care resources. Although decisions on optimal patient management must ultimately be made in accordance with best practices and clinical guidelines, there may be circumstances where less invasive strategies may be beneficial for patients requiring urgent care with limited critical care resources. Lastly, we acknowledge that except for emergency operations, each healthcare system will need to adjust prioritization of surgery based on available institutional resources and local COVID-19 epidemiology. The Society of Thoracic Surgeons (STS) has created a tiered patient triage guide that provides recommendations based on the COVID-19 hospital burden. 5 The hospital burden of COVID-19 is determined by the inpatient census of COVID-19 patients and reduction in operative capacity. Four tiers of inpatient COVID-19 load are described, and a strategy of case deferral is suggested in Table 1 according to the cardiac surgery acuity scale. Cases with Tier 4 acuity (urgent and inpatient) that cannot be performed, should be transferred to a center with operative capacity. Lastly, the STS has created two online instruments to assist in prediction of postoperative resource utilization. 6 All OR personnel should have adequate PPE as required by the local institution. Endotracheal intubation is known to be the highest risk AGP. 8 A specific sequence for airway management for all patients is shown in Table 2 . There are several other ventilator management strategies unique to cardiac surgery that must be considered. The first is ventilator management during sternotomy and other periods of mechanical ventilation hold. In these circumstances, circuit disconnection is strongly discouraged; during sternotomy, the ventilator is turned off for the period of time required by the surgeon and ventilation recommenced afterward. Circuit disconnection creates a high risk AGP scenario. 9, 10 The second consideration is precautions during the use of double-lumen endobronchial tubes for robotic and minimally invasive procedures or lung transplantation. To avoid the creation and dispersion of viral aerosols during periods of lung isolation, the lumen of the double-lumen tube needs to be firmly clamped and connected to a viral filter. Lastly, for transport, non- When possible, all other personnel should leave the room during the AGP. 3. If patient is anticipated to transfer to ICU, use 7.5 ETT or larger for adults. Preoxygenate well with 100% O 2 , patient breathing spontaneously. Maintain tight mask seal throughout; watch end-tidal O 2 to verify preoxygenation. 6. Don't tell patient to take "deep breaths" which may cause coughing. 7. Rapid sequence induction, without positive-pressure mask ventilation, if possible. If patient desaturates, use low tidal volume breaths. 8. Wait for complete muscle relaxation before laryngoscopy. Use of video-laryngoscopy is recommended. 9. If performing direct laryngoscopy to conserve GlideScope, wear full-face shield. 10. If using GlideScope to conserve full-face shields, wear regular eye protection. 11. Dispose of all airway equipment immediately. Team members not actively performing intubation should be encouraged to watch for any potential lapse in proper use of PPE. 13. Verify appropriate tube position and turn on ventilator. 14. Note the time when air circulation will turn over at least seven times following AGP. If staff needs to enter before this time, they should also wear a N-95 or PAPR. It is safe for staff to exit the room at any time as long as they are wearing N-95 masks. Abbreviations: AGP, aerosol-generating procedure; ICU, intensive care unit; PPE, personal protective equipment. In addition to ventilatory precautions, there are also necessary precautions endorsed by various national and international echocardiography societies when performing intraoperative transesophageal echocardiography (TEE). 10 Therefore, many centers have adopted a universal precaution Resources once taken for granted now must be carefully monitored to ensure availability before proceeding with cardiac surgery. The resources most limited and relevant include operating room staff, ventilators, and intensive care unit beds. Other crucial resources include cardiac medications, whose supply may be disrupted, as well as PPE and surgical gowns and drapes. The pandemic has also depleted routine blood donations which has led to a national shortage of blood products. We recommend a checklist that can be used preoperatively to ensure all necessary resources are available before operation (Table 3) . where the surge did not occur to the degree as expected, the "reopening" of elective cardiac surgery has already begun. This reopening will be in some manner a step-wise process as many primary care and cardiology practices have been operating on an alternate schedule for an extended period of time and some patients may be hesitant to seek attention for symptoms such as angina or dyspnea with exertion. 24 To maintain relationships with patients during the pandemic, many cardiac surgical practices have utilized telemedicine via video or phone conversations with high patient satisfaction rates. 25 Cardiac surgery patients are susceptible to postoperative infections and complications in the postcardiotomy setting, and multidisciplinary infection prevention vigilance is critical. Lastly, while clinical urgency will ultimately drive prioritization of surgery, consideration should also be given to planned patient disposition. Elderly patients who will require subacute nursing facility transfer rather than home discharge will often need to be tested for COVID-19 before discharge but may also be at risk due to multiple phases of care. Moreover, many outpatient cardiac rehabilitation programs have been postponed. Therefore, patients that require aggressive postoperative physical therapy may benefit from a delay in the scheduling of surgery. Extra-corporeal membrane oxygenation (ECMO) is a well-established therapy for acute cardiopulmonary failure. 28 Although existing guidelines and risk-assessment scoring systems have been previously useful for patient selection, their role in selecting patients with COVID-19 who would benefit from ECMO are poorly defined. 29 There is also concern that outcomes associated with ECMO use in disease and the combination of cardiac and pulmonary failure is currently associated with an extremely poor prognosis and may only benefit from advanced mechanical support therapies in highly selected patients. 35 7. Recognizing some of the concerning outcomes in this patient population, early referral to a Palliative Care Specialist should be encouraged. It is also important to recognize that the goals of ECMO, in general, are to allow the lungs (and potentially, the heart) to rest while avoiding barotrauma, oxygen-toxicity, and complications associated with tissue and end-organ ischemia associated with impaired oxygen-delivery from poor pulmonary function. ECMO is not a substitute for timely therapies directed toward disease management. Although there are concerns that VA-ECMO, as used to support acute cardiac and lung injury, has been associated with prohibitively poor outcomes, it is reasonable to consider ECMO for good candidates or a potential referral to an experienced center. 36 Although the exact number of ECMO cases for COVID worldwide is unclear, there have been almost 700 cases reported to the Extracorporeal Life Support Organization (ELSO) with 45% discharge alive rate. Most of the cases (>90%) are VV-ECMO with an average duration from intubation to ECMO of less than 4 days. Renal failure is common (up to 25% of cases) and the duration on ECMO has been approximately 8 days. 37 As this pandemic continues to evolve and ECMO utilization grows, it is imperative that such cases are tracked closely are reported to appropriate registries (ie, www.elso.org) to better understand the role of this supportive modality in this complex patient population. Pediatric patients seemingly have less severe symptoms. 47 Certain lesions may warrant special consideration given that some pediatric patients may be at increased risk for worse prognosis. 48 The effects of cyanosis and shunt dependent lesions will need to be followed more closely. These shunt dependent lesions may require earlier intervention for more stable pulmonary blood flow. Patients that will be adversely affected by a pulmonary infection will have to be closely monitored and may require more expedited surgical intervention. Congenital heart specialists are familiar with the effects of respiratory syncytial virus (RSV), influenza, and other respiratory viral infections on the timing of surgery. Children with CHD have more severe acute lower respiratory infection with RSV than children without CHD. 49 Elective cases that can be deferred for 6 months to a year should be rescheduled and closely followed using virtual platforms. When waiting, consideration must be given to the requirement for appropriate follow-up and unnecessary exposure to others vs moving forward with surgery. pandemic will require continued multispecialty collaboration, adaptability, and innovation. The authors acknowledge Ms Olivia Kranz for her assistance in coordination of this manuscript and Mrs Prezley Duncan for her assistance in organization of the manuscript for publication as well as graphics. Cardiac surgery in the time of the coronavirus COVID-19: Elective Case Triage Guidelines for surgical care American College of Cardiology's Interventional Council and the Society for Cardiovascular Angiography and Interventions. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from the ACC's interventional council and SCAI Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic Society of thoracic surgeons COVID-19 taskforce and the workforce for adult cardiac and vascular surgery Resource Utilization Tool. Society of thoracic surgeons COVID-19 resource prediction instrument Evidence of short-range aerosol transmission of SARS-CoV-2 and call for universal airborne precautions for anesthesiologists during the COVID-19 pandemic Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak Specific considerations for the protection of patients and echocardiography service providers when performing perioperative or perioprocedural transesophageal echocardiography during the 2019 novel coronavirus outbreak: council on perioperative echocardiography supplement to the statement of the american society of echocardiography Characteristics of health care personnel with COVID-19-United States Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak Preventing Contamination During Transesophageal Echocardiography in the Face of the COVID-19 Pandemic Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic Italian Society of Echocardiography and Cardiovascular Imaging Clinical outcome of 55 asymptomatic cases at the time of hospital admission infected with SARS-Coronavirus-2 in Shenzhen Diagnostic testing for severe acute respiratory syndrome-related coronavirus-2: a narrative review Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR Serial interval of COVID-19 among publicly reported confirmed cases Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing Anesthesia considerations and infection precautions for trauma and acute care cases during the COVID-19 pandemic Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic Telehealth and patient satisfaction: a systematic review and narrative analysis Safe reintroduction of cardiovascular services during the COVID-19 pandemic: guidance from North American Society Leadership Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from the Canadian Society of Cardiac Surgeons Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome A comparative analysis of survival prediction using PRESERVE and RESP scores Extracorporeal membrane oxygenation for coronavirus disease ECMO for ARDS due to COVID-19. Heart Lung Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure Extracorporeal membrane oxygenation in the treatment of severe pulmonary and cardiac compromise in COVID-19: experience with 32 patients Extracorporeal life support organization COVID-19 interim guidelines Advanced pulmonary and cardiac support of COVID-19 patients: emerging recommendations from ASAIO-a Living Working Document ECMO in COVID-19 Adult cardiac surgery and the COVID-19 pandemic: aggressive infection mitigation strategies are necessary in the operating room and surgical recovery COVID-19: a global transplant perspective on successfully navigating a pandemic Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China Clinical characteristics of coronavirus disease 2019 in China Virological assessment of hospitalized patients with COVID-2019 Profile of RT-PCR for SARS-CoV-2: a preliminary study from 56 COVID-19 patients Epidemiologic and clinical characteristics of heart transplant recipients during the 2019 coronavirus outbreak in Wuhan, China: a descriptive survey report First cases of COVID-19 in heart transplantation from China Quality measures for congenital and pediatric cardiac surgery Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China COVID-19 in children: initial characterization of the pediatric disease Acute lower respiratory infections associated with respiratory syncytial virus in children with underlying congenital heart disease: systematic review and meta-analysis Cardiac surgery considerations and lessons learned during the COVID-19 pandemic