key: cord-0818592-845omq33
authors: Niknam, Jonathan; Rong, Lisa Q.
title: Asymptomatic patients with coronavirus disease and cardiac surgery: When should you operate?
date: 2020-08-02
journal: J Card Surg
DOI: 10.1111/jocs.14918
sha: 5cf77d8329db265d86e52221d7b938c922bc6c29
doc_id: 818592
cord_uid: 845omq33

The coronavirus disease (COVID) pandemic and the decision‐making process of whether to perform urgent procedures during a surge are issues that will likely not disappear in the near future as reflected by the current rise in COVID cases in the southern and western United States and the resurgent numbers of confirmed cases around that world leading to are leading to new lock‐downs. Multi‐disciplinary discussions will continue to be important to decide individual risk and benefit profiles for patients with asymptomatic COVID patients moving forward. While imperfect, this most recent study provides more insight to some of the risks that should be weighed in these discussions. Further prospective, longitudinal research and better understanding of the heterogeneity of the COVID positive patient will further enhance understanding the decision‐making process in the cardiac surgical patient through these difficult times.

perfect, this most recent study provides more insight to some of the risks that should be weighed in these discussions. Further prospective, longitudinal research and better understanding of the heterogeneity of the COVID positive patient will further enhance understanding the decision-making process in the cardiac surgical patient through these difficult times. (67%) of these patients died. Another patient with morbid obesity who had been scheduled to undergo bariatric surgery was brought to the emergency room 1 day before his operation for severe respiratory distress which rapidly escalated to cardiopulmonary arrest.

Both authors note that the physiologic stressors induced during surgery and anesthesia, such as atelectasis and proinflammatory changes, may exacerbate the pre-existing COVID-19 infection.

However, this study is needed as the cardiac surgical patient population is unique in that it is both high-risk for adverse outcomes with COVID and cardiac morbidity if they do not have immediate surgical intervention for symptomatic heart disease. Therefore, the level of urgency is higher than in elective noncardiac surgery and the patients are usually sicker. In addition, in this patient population described by Barkhordari et al, cardiopulmonary bypass and the need for continued mechanical ventilation post-surgery further increases risk of pulmonary injury. 5 Anesthetic management of these patients in the study included a lung-protective strategy as recommended for COVID-19 patients.

Tidal volumes of 6 to 8 mL/kg IBW were employed, with ventilatory parameters being adjusted on the basis of hemodynamics and ABG data. However, pH was not reported in this study. Pulmonary considerations for the anesthetic management of COVID-19 positive cardiac surgical patients aim for a pH greater than or equal to 7.25. 6 Specific details of peri-operative acid-base management and permissive hypercapnia are warranted in the future analyses of postoperative respiratory outcomes in cardiac surgical patients with COVID.

Although the study included both urgent and emergent proce- the Center for Disease Control note that "replication-competent virus has not been successfully cultured more than 9 days after onset of illness," and "Among those who continue to have detectable RNA, concentrations of detectable RNA 3 days following recovery are generally in the range at which replication-competent virus has not been reliably isolated by CDC." This might serve as a timeline as to when to safely operate on a patient who has recovered from COVID-19 with a persistently positive PCR test. However, there are further concerns that a persistent positive test may reflect a re-infection.

In addition, different institutions have evolving recommendations for the timing of COVID PCR before the scheduled procedure:

while testing 24 to 48 hours before a procedure was previously preferred early in the pandemic, negative tests up to 5 days can be acceptable as numbers have dwindled in the Northwest. This increased time from testing to procedure may increase the likelihood of an asymptomatic carrier with a negative COVID test being brought in for elective surgery.

The COVID pandemic and the decision-making process of whether to perform urgent procedures during a surge are issues that will likely not disappear in the near future as reflected by the current rise in COVID cases in the southern and western United States and the resurgent numbers of confirmed cases around that world leading to are leading to new lock-downs. Multi-disciplinary discussions will continue to be important to decide individual risk and benefit profiles for patients with asymptomatic patients with COVID moving forward. While imperfect, this most recent study provides more insight to some of the risks that should be weighed in these discussions.

Further prospective, longitudinal research and better understanding of the heterogeneity of the COVID positive patient will further enhance understanding the decision-making process in the cardiac surgical patient through these difficult times.

Lisa Q. Rong http://orcid.org/0000-0003-0982-7154

COVID-19: guidance for triage of non-emergent surgical procedures

Early respiratory outcomes following cardiac surgery in patients with COVID-19

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

COVID-19 outbreak and surgical practice

Incidence and risk factors of pulmonary complications after cardiopulmonary bypass

Chinese society of anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019

Review of "adult cardiac surgery during the COVID-19 pandemic: a tiered patient triage guidance statement

Persistent positivity and fluctuations of SARS-CoV-2 RNA in clinically-recovered COVID-19 patients

Temporal dynamics in viral shedding and transmissibility of COVID-19

html?CDC_AA_refVal=https%3A%2F%2Fwww. cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcommunity%2Fstrategy-discontinue-isolation.html How to cite this article: Niknam J, Rong LQ. Asymptomatic patients with coronavirus disease and cardiac surgery: When should you operate?