key: cord-0821181-gqmiwmbp
authors: Grant, Michael C.; Lother, Sylvain A.; Engelman, Daniel T.; Hassan, Ansar; Atluri, Pavan; Moosdorf, Rainer; Hayanga, J Awori; Merritt-Genore, HelenMari; Chatterjee, Subhasis; Firstenberg, Michael S.; Hirose, Hitoshi; Higgins, Jennifer; Legare, Jean-Francois; Lamarche, Yoan; Kass, Malek; Mansour, Samer; Arora, Rakesh C.
title: Surgical Triage and Timing for Patients with COVID: A Guidance Statement from the Society of Thoracic Surgeons
date: 2022-05-18
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2022.05.001
sha: 4da02f60fae032986483de0f8d7899157dfb8528
doc_id: 821181
cord_uid: gqmiwmbp

The coronavirus disease 2019 (COVID-19) pandemic continues to disrupt the provision of cardiac procedural services due to overwhelming interval surges in COVID-19 cases and the associated crisis of cardiac intervention deferment. Despite the availability of widespread testing, highly efficacious vaccines, and intensive public health efforts, the pandemic is entering its third year where new SARS-CoV-2 variants have increased the likelihood that patients scheduled for cardiac intervention will contract COVID-19 in the perioperative period. The Society of Thoracic Surgeons (STS) Workforce on Critical Care, the Workforce on Adult Cardiac and Vascular Surgery and the Canadian Society of Cardiac Surgeons have developed this document, endorsed by the STS and affirmed by the Society of Cardiovascular Angiography and Interventions and the Canadian Association of Interventional Cardiology, to provide guidance for cardiac procedure deferment and intervention timing for preoperative patients diagnosed with COVID-19. This document is intended for the perioperative cardiac surgical team and outlines the present state of the pandemic, the impact of COVID-19 on intervention outcome, and offers a recommended algorithm for individualized cardiac procedure triage and timing.

The coronavirus disease 2019 pandemic continues to disrupt the provision of cardiac procedural services due to overwhelming interval surges in COVID-19 cases and the associated crisis of cardiac intervention deferment. Despite the availability of widespread testing, highly efficacious vaccines, and intensive public health efforts, the pandemic is entering its third year where new SARS-CoV-2 variants have increased the likelihood that patients scheduled for cardiac intervention will contract COVID- 19 At the time of writing of this manuscript, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 , is now responsible for more than 410 million cases and 5.8 million deaths worldwide. 1 During the initial wave of the pandemic, healthcare systems were overwhelmed by both the volume and severity of disease, requiring expansion of existing intensive care units, deferment of non-urgent services and redeployment of healthcare providers and staff. [2] [3] As a result, cardiac surgical researchers have identified a crisis of deferment, whereby patients, unable to be treated in a timely fashion, present both in large numbers and in clinical extremis, further taxing the already constrained medical system. An association has emerged between regional COVID-19 activity and reduced non-urgent cardiac procedural volume, accompanied by a later influx of decompensated patients seeking urgent cardiac intervention. [4] [5] [6] Over the past two years, the development of highly efficacious vaccines, new effective therapies, and public health efforts to limit transmission have allowed hospital systems to continue to offer a broad range of services amidst the pandemic. Despite intensive efforts, conditions have given rise to multiple SARS-CoV-2 virus variant mutations, each with a unique profile in terms of their relative contagiousness and severity of illness, and each associated with a surge in population disease and regional hospital admissions. [7] [8] The most recently identified variant, designated omicron, is notable for a significant replication advantage, greater asymptomatic disease carriage, and immune evasion, leading to more effective transmissibility. 9 Although associated with an overall lower disease severity, 10 the J o u r n a l P r e -p r o o f sheer number of COVID-19 cases have led to hospital and ICU admissions rates that are comparable or greater to those from prior pandemic waves.

To identify and prevent COVID-19 disease spread, hospital-based in-patient testing programs have become commonplace for patients undergoing non-urgent procedures across the North America. The emergence of the omicron variant has driven test positivity rates to alarmingly high levels, with more than 25% of patients (regardless of symptoms) testing positive for SARS-CoV-2 in high prevalence locations. 11 While this highlights a remarkable disease burden and reflects the degree of asymptomatic carriage that typifies omicron, 12 there is still significant variability in symptom severity, ranging from asymptomatic to acute respiratory distress syndrome (ARDS). Inflammatory responses associated with acute COVID-19 may also exacerbate underlying comorbid illnesses and lead to clinical deterioration. A positive SARS-CoV-2 test thus typically leads to a period of clinical observation for symptom evolution, treatment, and recovery from acute viral illness, leading to further delays for necessary procedures. For patients awaiting cardiac procedures, even modest delays can contribute to significant morbidity and mortality.

This document serves to provide guidance and clinical recommendations for triage and timing of cardiac patients who contract COVID-19 prior to surgery. In generating this document, it is recognized that data pertaining to this topic is evolving rapidly, almost on a daily basis. As such, the recommendations within this guidance document are based upon the best available evidence and would be subject to update with discovery of new information. 

Prior guidance from the Society of Thoracic Surgeons (STS) and others has provided detailed recommendations regarding general cardiac service line procedure deferment, which includes the tailoring essential services according to local COVID-19 disease burden and existing hospital resource infrastructure. [13] [14] The guidance ranges from Tier 1, involving mild reduction in cardiac surgical capacity and modest deferment of primarily patients with asymptomatic cardiac disease undergoing non-urgent procedures, to Tier 4, which limits services to only emergency cardiac surgery due to extreme reduction in operative capacity (Table 1) In addition, the STS has recommended universal preoperative SARS-CoV-2 testing, particularly in areas with high disease burden. [15] [16] Preoperative molecular testing (i.e., polymerase chain reaction; PCR) is preferred, due to its high level of sensitivity and specificity, 17 international prospective cohort study that showed pulmonary complications and adjusted 30-day mortality remained significantly elevated in SARS-CoV-2 positive patients for the first 6 weeks after diagnosis compared to those without SARS-CoV-2. 31 Patients who underwent surgery after symptom resolution and > 7 weeks after diagnosis had a postoperative complication risk similar to baseline, however, patients who remained symptomatic at the time of deferred surgery still conferred a greater mortality risk. 31 This suggests a lengthier deferment of surgery is necessary in cases of persistent or prolonged symptoms. Lastly, a recent study involving patients undergoing major elective surgery showed a significant increase in postoperative mortality within 4 weeks, and risk of pulmonary complication remained elevated for 8 weeks after COVID-19 diagnosis. 32 As a result, in order to confer the lowest risk of COVID19-related complication, preference for the latter end of the deferment time period is recommended.

Although specific data that pertains to the cardiac patient on procedure timing is sparse, these recommendations are consistent with recent guidance regarding procedural delays, which recommends between 4-12 weeks postponement in patients with positive SARS-CoV-2 diagnosis who are scheduled for intermediate acuity elective (non-urgent) procedures (i.e., certain stable forms of valvular disease) and greater than 12 weeks in low acuity (i.e., generally asymptomatic cardiovascular disease) settings. 33 

The decision to proceed or defer urgent intervention in a patient with COVID-19 requires weighing the risk associated with perioperative COVID-19 and cardiovascular disease progression against the potential benefit associated with cardiovascular intervention. If 

If the procedure is deemed emergent, or if procedural indication becomes emergent during the period of procedural delay, it is advisable to proceed immediately with intervention assuming teams observe the necessary precautions to avoid disease transmission, which are outlined in full in prior guidelines. 15 Exceptions apply to patients with severe COVID-19, who are considered poor candidates for emergent cardiovascular intervention, due to the nature of their present clinical condition and potential futility of procedural J o u r n a l P r e -p r o o f intervention, which in itself confers substantial perioperative risk, and consideration should be made rather for patient-centered goals of care discussion.

Overall, as clinicians attempt to determine an individual's appropriateness and timing for cardiac procedures, consideration should be made not only for the cardiac disease severity and accompanying procedure urgency, but also for the severity of COVID-19 symptoms and their hospital's present COVID-19 response tier.

Patients with procedural delay greater than 90 days from a positive test result should undergo repeat preoperative COVID-19 testing to screen for potential reinfection, whereas testing prior to this timeframe may result in increased false positives, particularly with molecular testing. 19, 32 Subsequent procedure triage and timing would follow the outline above. Repeat preoperative cardiopulmonary testing and preoperative optimization is advised for all patients with significant decline in interval functional status or residual upper respiratory or pulmonary symptoms (i.e., shortness of breath, exertional dyspnea, syncope, oxygen requirement). Testing may include pulmonary function testing, computerized tomography scan, cardiac echocardiography or additional cardiovascular interrogation as necessary for procedural planning. Continued or worsened clinical symptoms may be the result of advancement in cardiovascular disease or residual myocardial or cardiopulmonary effects of COVID-19 and should therefore be taken into consideration as part of planning for their cardiac intervention.

At present, there is no convincing evidence to suggest that a specific anesthetic maintenance (i.e., inhaled versus total intravenous anesthetic), airway management selection (i.e., intubation versus monitored anesthesia care) or the use of regional anesthesia is associated with more favorable postoperative outcomes in the setting of recent COVID-19. 30 Similarly, there are no studies that have investigated the effect of specific COVID-19 treatments (i.e., steroids, immunomodulators) on subsequent surgical timing or postoperative outcome. Therefore, traditional perioperative screening, risk profiling and optimization should be applied to all patients.

The COVID-19 pandemic has disrupted the provision of cardiac procedural services with an overwhelming series of surges in COVID-19 cases and precipitated an associated crisis of cardiac intervention deferment. We strongly encourage Heart Teams to engage patients and their families in decision-making. Determination of procedural timing and triage is based on a combination of an individual's risk of COVID-19 associated complications and cardiac procedure urgency. Defer asymptomatic or truly elective procedures.

2; 30-60%, moderate reduction

All inpatients (urgent, emergent surgery), outpatients with the progressive symptoms or fail medical management.

Defer asymptomatic or elective procedures for patients who can be medically managed.

3; 60-80%, severe reduction

All inpatients who cannot be discharged safely without intervention.

Defer all outpatients unless meeting urgent criteria for admission.

Only emergency services based on resources available.

Defer all outpatients and inpatients who can wait. 

Ongoing refractory cardiac compromise, with or without hemodynamic instability, not responsive to therapy except for procedural intervention. Procedural delay is life threatening.

Intervention is required during the same hospitalization to avoid further clinical decompensation. Inpatient monitoring and medical therapy are necessary to avoid clinical compromise.

Stable cardiac function in the time frame prior to intervention without evidence of further clinical decompensation. Procedural delay with remote symptom management is unlikely to contribute to clinical decline. J o u r n a l P r e -p r o o f Table 3 .

Asymptomatic Diagnosis based upon preprocedural test result, no clinical signs or symptoms of illness.

Mild Symptomatic (i.e., cough, dyspnea, fever, congestion, fatigue), but do not require hospitalization for management.

Symptomatic, requiring hospitalization or those with comorbidities with high risk of disease progression (i.e., diabetes) or immunocompromised status Severe Symptomatic, requiring organ supportive therapies including high flow nasal oxygen, and/or positive pressure ventilation (i.e., CPAP/BiPap) and/or, mechanical ventilation and/or vasopressors/inotropes a Including patients with diabetes or immunocompromised status. b Assuming either resolution or improvement in COVID-19 symptoms and based upon the results of Shared Decision-Making and Heart Team discussion (i.e., risk of further surgical delay is greater than the perceived risk of surgery in the setting of COVID-19 illness). c Assuming provision of the necessary COVID-19 precautions.

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