key: cord-0686258-zcyk0w21 authors: Czerny, Martin; van den Berg, Jos; Chiesa, Roberto; Jacobs, Michael; Jakob, Stephan; Jenni, Hans‐Jörg; Lorusso, Roberto; Pacini, Davide; Quintana, Eduardo; Rylski, Bartosz; Staier, Klaus; Tsilimparis, Nikolaos; Wyss, Thomas; Gottardi, Roman; Schmidli, Juerg title: Management of acute and chronic aortic disease during the COVID‐19 pandemic—Results from a web‐based ad hoc platform date: 2020-10-08 journal: J Card Surg DOI: 10.1111/jocs.15093 sha: 1dcd2b2bad8e636ef9be35126252282786252c70 doc_id: 686258 cord_uid: zcyk0w21 BACKGROUND: To share the results of a web‐based expert panel discussion focusing on the management of acute and chronic aortic disease during the coronavirus (COVID‐19) pandemic. METHODS: A web‐based expert panel discussion on April 18, 2020, where eight experts were invited to share their experience with COVID‐19 disease touching several aspects of aortic medicine. After each talk, specific questions were asked by the online audience, and results were immediately evaluated and shared with faculty and participants. RESULTS: As of April 18, 73.3% answered that more than 200 patients have been treated at their respective settings. Sixty‐four percent were reported that their hospital was well prepared for the pandemic. In 57.7%, the percentage of infected healthcare professionals was below 5% whereas 19.2% reported the percentage to be between 10% and 20%. Sixty‐seven percent reported the application of extracorporeal membrane oxygenation in less than 2% of COVID‐19 patients whereas 11.8% reported application in 5%–10% of COVID‐19 patients. Thirty percent of participants reported the occurrence of pulmonary embolism in COVID‐19 patients. Three percent reported to have seen aortic ruptures in primarily elective patients having been postponed because of the anticipated need to provide sufficient ICU capacity because of the pandemic. Nearly 70% reported a decrease in acute aortic syndrome referrals since the start of the pandemic. CONCLUSION: The current COVID‐19 pandemic has—besides the stoppage of elective referrals—also led to a decrease of referrals of acute aortic syndromes in many settings. The reluctance of patients seeking medical help seems to be a major driver. The number of patients, who have been postponed due to the provisioning of ICU resources but having experienced aortic rupture in the waiting period, is still low. Further, studies are needed to learn more about the influence that the COVID‐19 pandemic has on the treatment of patients with acute and chronic aortic disease. Current adaptions according to the anticipated needs for intensive care capacity in patients suffering from coronavirus (COVID-19) disease have led to a near to complete stop of referral of elective cases in many in cardiovascular medicine and in particular in cardiac surgery. Acute and chronic thoracic aortic pathology has become one of the major drivers of growth in this field and the share of patients with aortic disease exceeds more than 20% in many settings. 1 The specific themes that were focused upon have been managed in general starting at the referral level. Examples for dealing with acute aortic syndromes were provided starting with acute type A aortic dissection, descending aortic disease as well as infrarenal aortic disease. In addition, coagulation disorders as well as specific measures at the intensive care unit (ICU) were discussed. All aspects focused on patients with suspected and confirmed disease. In addition, extracorporeal membrane oxygenation (ECMO) aspects in patients with aortic disease were discussed. The San Raffaele Hospital is in the epicenter of the Italian epidemic. emergency room are tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) , and a chest computed tomography (CT) is performed. In case of suspect or confirmed COVID-19 in a patient requiring surgical therapy, full personal protective equipment (PPE) for the entire surgical team is available outside of the dedicated COVID-19 operating theatre. In case of general anesthesia, the surgical team waits outside the room while the patient is intubated and for another 15 min thereafter to allow clearance of the air from any aerosols origination from the intubation. Figure 1 shows the distribution of acute cases within the first 6 weeks if the epidemic. The S. Orsola Hospital, University of Bologna, is located in the Emilia-Romagna region close to Lombardia and is also one of the main regional Hub centers attending the COVID-19 network. According to the initial experience with COVID-19, the department of cardiac surgery observed a significant reduction in the incidence of acute aortic syndromes since the beginning of the pandemic. Usually, 8-10 acute aortic syndromes per month are admitted while in March only two patients have been treated. In Switzerland, it is currently forbidden by law to carry out nonurgent examinations and interventions/treatments. Physicians need to justify the urgency for every patient that is scheduled for a procedure. It has been recommended to avoid CO 2 insufflation into the operative field as this can lead to aerosolization and virus spread. Also, electrocautery should be attached to a sucker to capture smoke that can lead to aerosolization. One additional aspect of care in cardiothoracic surgery is to protect the exits of the thoracic drains that are underwater seal with continuous wall suction and bacterial filters to avoid environmental contamination. A case of a 79-year-old female mirrored the currently altered frame conditions. COVID-19 was suspected without major evidence and besides the computed tomography angiography (CTA), a swab test was taken. The CTA confirmed the diagnosis of acute type A aortic dissection and hardened suspicion because of bilateral ground-glass areas at both inferior lobes suggestive of interstitial pneumonia (Figure 3 ). It took more than 5 h (320 min) for the patient to arrive in the operating room since her arrival in the ER to comply with all the safety protocols. The patient underwent an hemiarch and aortic valve replacement under moderate hypothermia and bilateral selective cerebral perfusion without any operative complication. All the involved sanitary were dressed with special protection devices. The first swab test in the ICU resulted in negative; however, according to the infectiologist, she was treated as a COVID-19 patient with hydroxychloroquine 400 mg (for 5 days) and azithromycin 500 mg (for 3 days) daily. Postoperative course was regular. During hospitalization, she repeated two more times the COVID-19 tests but still negative and continue to assume antibiotic treatment until normalization of chest X-ray. The patient was discharged after 13 days in a local rehabilitative hospital. It is also known that viruses can lead to an unbalanced provoking generation of reactive oxygen species (ROS) 4,5 with exceeding oxidative distress. 6 ROS but also virus-nucleocapsides directly can stimulate neutrophils to produce neutrophil extracellular traps (NETs). 7, 8 NETs are highly thrombogenic and there is evidence, that NETs play a major role in the pathophysiology of HIT Type II. 9 F I G U R E 3 CTA of a patient with acute type A aortic dissection and suspicion of COVID-19 disease due to unspecific pulmonary infiltrates. COVID-19, coronavirus; CTA, computed tomography angiography F I G U R E 4 CTA after total endovascular aortic arch repair for acute type A aortic dissection. CTA, computed tomography angiography CZERNY ET AL. Coagulation disorders in COVID-19 patients show striking similarities with patients that reveal a HIT Type II coagulation disorder. 10 further NET formation. 11 There is also evidence that platelets play an important role in antiviral defense. 12 Platelet activation is frequently observed during viral infections. 13 Activated platelets form aggregates with neutrophils and stimulate NETosis. 14 Massive activation of the platelet/neutrophil axis and subsequent NET-based clearance mechanisms may represent an emergency strategy of the host in the face of systemically multiplying viruses. 15 This reaction is followed by a drop in platelet counts, which is observed in many viral infections. The degree of platelet loss correlates with the severity of virus-induced disease and determines the clinical outcome. 16, 17 Regarding the perioperative treatment of aortic patients, several questions remain to be answered such as to the heparin strategy Also, patients with COVID-19 disease must be protected. Their lungs can be harmed by atelectasis, overdistension, and high breathing frequency-either self-inflicted if breathing spontaneously or as a result of inappropriate ventilator settings. 19 It is important to realize that ventilators used for anesthesia often do not provide all necessary information and options to ventilate complicated lung diseases such as ARDS. Furthermore, coagulation is abnormal in many patients with COVID-19 disease-sometimes, these abnormalities are cardinal symptoms of the disease. 20 Careful monitoring of coagulation and adapted anticoagulation are mandatory. Further organs involved are the heart and the kidney. Their function should also be closely monitored, given that pharmacological treatment often used in patients with COVID-19 disease may interfere with their function (e.g., vasopressors and diuretics). 21 ECMO has become a major contributor to the treatment armamentarium of COVID-19 disease. Currently, several ad hoc registries are collecting large amounts of data aiming at gaining knowledge of risk factors for the need of ECMO therapy as well as for the probability of successful weaning and finally outcome. 22 Currently, no experience in aortic patients with COVID-19 disease are available neither among this group of experts nor in the current literature. • Q & A 2. Was your hospital well prepared before the first COVID-19 patient was admitted? Sixty-four percent were reported that their hospital was well prepared for the pandemic. What is the percentage of infected healthcare professionals in your hospital? In 57.7%, the percentage was below 5% whereas 19.2% reported the percentage to be between 10% and 20%. • Q & A 4. Was complete personal protective equipment available for all healthcare professionals caring for COVID-19 patients? Seventy-four percent reported that their settings have been/are adequately equipped regarding personal protective equipment. • Q & A 5. What kind of personal protective equipment was lacking in your hospital? In 37.5%, FFP-3 masks were lacking, followed by adequate protection goggles, gloves, and gowns. • Q & A 6. How many COVID-19 patients were treated with ECMO in your hospital? Sixty-seven percent reported ECMO application in less than 2% of COVID-19 patients whereas 11.8% reported application in 5%-10% of COVID-19 patients. • Q & A 11. When do you plan to restart with elective cases in your hospital? More than 40% were able to report a planned resume of regular practice as of the beginning of May 2020. • Q & A 12. Do you routinely test/screen elective aortic/vascular patients for COVID-19? More than 50% reported to apply regular screening measures in planned referrals. patients. This is in line with the known pathophysiologic mechanisms of the disease affecting the coagulation system and thereby underlying the need to rethink and adapt perioperative coagulation strategies after surgery and in particular in patients in need for substantial substitution of plasmatic and cellular coagulation, such as after major aortic surgery. [15] [16] [17] Several participants reported patients with acute type A aortic dissection and COVID-19 infection. Fortunately, the number of patients who experienced aortic rupture due to being postponed because of the anticipated need for ICU capacity for COVID-19 patients was low. This mirrors a diligent triage but it remains clear that the need for treatment in these patient remains and an asymmetric demand will develop as soon as the referral embargo is loosened. Participants also reported a substantial decrease in referrals for acute aortic syndromes which can only be interpreted as a reluctance of patients to seek medical help. This potentially dramatic decline will be subject of further research from this group. Finally, there was heterogeneity with regard to the prophylactic testing or nontesting of patients before entering the hospital. Many settings report standard measures like a simple questionnaire and taking temperature for initial stratification. Summarizing, the current COVID-19 pandemic has-besides the stop of elective case referrals-also led to a decrease of referrals of acute aortic syndromes in many settings. The reluctance of patients seeking medical help seems to be a major driver. The number of patients, who have been postponed but having experienced aortic rupture in the waiting period, is still low. Further studies are needed to learn about the context of aortic disease and the COVID-19 pandemic. Victor Bilman, MD, Matteo Bossi, MD, Renata Castellano, MD, ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. 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