key: cord-0804417-j107pf8u
authors: Engelman, Daniel T.; Chatterjee, Subhasis
title: Commentary: Can we do better during a potential second wave of COVID-19?
date: 2020-11-02
journal: JTCVS open
DOI: 10.1016/j.xjon.2020.10.008
sha: 7b2a2aca26a11bd9967d45c98084fc0d4311a242
doc_id: 804417
cord_uid: j107pf8u

nan

Preoperative screening and isolation of COVID-19-positive patients permitted safe delivery of 4 major cardiac/thoracic surgery in the initial wave of the pandemic and will be useful during 5 future waves. 6 7 J o u r n a l P r e -p r o o f Engelman and Chatterjee 2 As hospitals prepare for a second wave (or third wave, depending on who's counting) of novel 8 coronavirus 2019 (COVID-19), and the United Kingdom considers another national lockdown, 1  9 we should pause to review our experiences providing cardiothoracic surgical care during the 10 initial wave of the pandemic. In this month's JTCVS Open, Balmforth and colleagues 2 describe 11 how they safely delivered major cardiac and thoracic surgery at a tertiary referral center in 12

London during the first 7 weeks of the pandemic. Their comprehensive protocol included 13 preoperative COVID-19 screening, full personal protective equipment during aerosol-generating 14 procedures, and physical separation of COVID-19-positive patients-tactics that align closely 15 with North American cardiothoracic societies' guidance statements. 3,4 16

The authors report 9% cardiac surgical mortality, with 12% of all patients testing positive 17 for COVID-19. 2 No patients converted to COVID-19 positivity while hospitalized. During the 18 study period, 1996 patients were admitted to that hospital with confirmed COVID-19 infection. 19

Of these, 361 (18%) were admitted to the intensive care unit (ICU), 281 (14%) required 20 mechanical ventilation, and 19 (1%) received extracorporeal membrane oxygenation. These 21 percentages are consistent with US results. 5 A reduction in surgical volume was noted, primarily 22 from reduced staff availability due to intensive care capacity reallocation to the treatment of 23 COVID-19 patients. Some case selection triaging was undertaken to prioritize reduced resources. 24

Because lower-risk patients who could reasonably defer surgery were discharged, the remaining 25 operative cohort was a higher-risk group than before the pandemic. 26

This type of triaging has been previously reported. 6,7 The authors noted a 60% reduction 27 in surgical volume compared to the previous year, consistent with the global 50%-75% reduction 28 similarly reported. 8 The protocol implemented to screen surgical candidates and isolate those 29 with COVID-19 was successful in maintaining a COVID-19-secure environment for all patients. 30

This pandemic may still be in its early phases. In the United States, <10% of adults had 33 COVID-19 antibodies as of July 2020. 10 Although Balforth and colleagues 2 suggest that parallel 34 services can be provided safely despite high disease prevalence, resource scarcity may severely 35 hinder any ramp-up of non-COVID-19 cases. 3,4 Additionally, as we consider ways to better 36 address a potential second wave, we must improve our surveillance testing of asymptomatic 37 healthcare workers, up to 40% of whom may test positive for COVID-19. 11 38

The timing of testing also should be reassessed. In infected-but-asymptomatic 39 individuals, the false-negative rate for polymerase chain reaction testing is 75% in the first 40 5 days after exposure but decreases to about 20% 6-10 days postinfection. 12 National policies 41 governing facial coverings, social distancing, and indoor dining based on up-to-date scientific 42 data and local disease prevalence would seem warranted. The US Centers for Disease Control 43 reported that adults with confirmed COVID-19 were twice as likely as controls to have dined at a 44 restaurant in the 14 days before becoming ill 13 (although correlation is not causation). 45

This manuscript correctly points out that we can maintain basic levels of urgent and 46 emergency healthcare during a pandemic. However, the delays in elective and preventative care-along with social isolation, elevated stress, and job and food insecurity-have accelerated 48 mortality to nearly 600,000 more deaths than would normally be predicted among 30 nations 49 from the onset of the pandemic to the end of July. 14 

Ramping up 66 delivery of cardiac surgery during the COVID-19 pandemic: a guidance statement from 67 the Society of Thoracic Surgeons COVID-19 Task Force

Adult cardiac 70 surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are 71 necessary in the operating room and surgical recovery

Coronavirus disease 2019 pandemic measures: reports from a national survey of 9,120 75 ICU clinicians

Adult cardiac 77 surgery during the COVID-19 pandemic: a tiered patient triage guidance statement