key: cord-0875723-k5astcyh authors: Campbell, Lorraine; Price, Susanna title: Cardiothoracic intensive care in the time of COVID-19 date: 2021-08-28 journal: Eur Heart J Acute Cardiovasc Care DOI: 10.1093/ehjacc/zuab076 sha: a2afc91a77be787b81230f094514f52625fdcb65 doc_id: 875723 cord_uid: k5astcyh nan bed numbers increased from 18 to 56 mid-wave 1 and as the demand for veno-venous extracorporeal membrane oxygenation (VV-ECMO) rose across the country RBH provided VV-ECMO for up to 27 patients simultaneously. Despite initial discussions amongst the global ECMO community concerning the use of VV-ECMO in COVID-19, 3 with uncertain efficacy and high resource utilization, outcomes were excellent. Indeed, at 6 months, using standardized referral/acceptance criteria, 4 RBH survival was significantly higher in COVID-19 VV-ECMO patients than non-COVID-19 patients (84.9% vs. 66.0%), but at the cost of significantly longer VV-ECMO runs (19 vs. 11 days). 5 Early reports from China suggested a high incidence of acute myocarditis. Globally, however, there was little requirement for VA-ECMO (3%). 6 When seen, left ventricular dysfunction resolved rapidly using VA-ECMO with zero mortality. These outcomes were only achieved by respecting the National chain of command for pandemic response, implementation of a local command-control structure and wholesale redeployment of our highly specialist cardiothoracic teams to deliver critical care under the guidance of our ICUs. Rapid implementation of remote technology facilitated flow of communication between clinicians, patients, and families. 7 This included establishing virtual ICU support for frontline workers (often redeployed), real-time video feeds of ventilator waveforms/patient monitors and webcam-enabled workstations providing live, hands-free video communication with staff working in personal protective equipment (PPE). A multidisciplinary ethics committee afforded advice/guidance, and a family liaison team provided daily remote communication with relatives. COVID-19 research continued as part of local, national, and international collaborations. The reallocation of ICU beds and staff meant cardiac surgery in London was entirely restructured, forming a Pan-London Emergency Cardiac Surgery service, providing urgent/emergency surgery for the whole of London, co-ordinated across just two centres. 8 Following wave 1, RBH was mandated to continue with double the ICU bed capacity in order to now provide both 'green pathways' for patients requiring specialist cardiac interventions (to at least 90% of prepandemic levels) as well as continued provision of VV-ECMO. Restarting cardiac services with a guarantee that our patients would have totally separate, secure pathways proved almost more challenging that the initial emergency response but was equally vital. As we move to a more endemic phase, several lessons emerge. First, the adaptability of specialist cardiothoracic centres with their highly skilled staff familiar with using complex technology, is an extraordinary and uniquely flexible resource. Second, in-depth discussions regarding social justice, ethical decision-making and research in a time of pandemic are only just beginning and must inform future practice. 3, 9, 10 Third, hierarchy-based models of training in ICU can be readily and successfully exchanged for task-based models. Finally, this pandemic was no black swan event 1 ; it was predictable, and indeed predicted. As we continue to learn about COVID-19 and each new variant, many uncertainties persist, but our role to advocate for our critically ill cardiac patients remains. 11 Conflict of interest: none declared. The Corona crisis: a wicked problem COVID-19 and disruptive modifications to cardiac critical care delivery: JACC Review Topic of the Week Should we ration extracorporeal membrane oxygenation during the COVID-19 pandemic? Six-month mortality in patients with COVID-19 and non-COVID-19 viral pneumonitis managed with veno-venous extracorporeal membrane oxygenation Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry Rapid deployment of virtual ICU support during the COVID-19 pandemic The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic Ethical decision making during a healthcare crisis: a resource allocation framework and tool Allocating scarece intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks Is COVID-19 the deadliest event of the last century?