key: cord-0896832-mzubhw88
authors: El-Saiedi, Sonia A.; Haeffele, Christiane; Matta, Baher H.; Lui, George K.
title: The Hidden Victims of COVID-19 Pandemic: Congenital Heart Disease Patients
date: 2020-06-15
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.05.081
sha: 0ba11c0f771e47cc0886ff422e71af9ddac425ff
doc_id: 896832
cord_uid: mzubhw88

nan

Tweet summary/ Abstract: The COVID-19 pandemic has resulted in unprecedented challenges to the congenital heart disease community. In Egypt, a country with limited resources, hospitals have limited admission to urgent cases in order to preserve hospital beds and resources for COVID-19 patients. Only critical neonates with congenital heart disease (CHD) are offered services at this time. In the United States, elective procedures for CHD patients have been canceled nationwide due to the pandemic. CHD patients are hesitant to seek medical care for fear of exposure to COVID-19. While it is not yet known how many CHD patients may be lost to follow-up or delay needed testing or intervention because of COVID-19, we must begin to mitigate this impact on CHD patients as the consequences will only contribute to the collateral damage of COVID-19 on these hidden victims. Organ transplantation has ceased, leaving critically ill patients without options. A report addressing pitfalls in behavior during the COVID-19 pandemic noted the uneven distribution of cases within and between countries will lead to inequalities in care (7) . In this silent void of care, as international focus shifts to COVID-19, CHD patients are at risk of dying at home and/or developing complications from their cardiac condition. They are among the hidden victims of the COVID-19 pandemic.

Several themes have emerged from the literature regarding the impact of COVID-19 on congenital cardiac programs (8) (9) (10) . Limited resources such as hospital beds, ventilators, and blood products have resulted in difficult decisions regarding timing of CHD surgery. When healthcare resources become scare due to increased demand and must be rationed, a triage system becomes necessary (11) . A triage system must be founded on transparency and based on committee decision, to avoid individual bias and singular responsibility for care allocation. Shared decision making amongst medical and surgical teams is essential to implement timing of CHD intervention when there are less resources. General guidance for timing of CHD intervention has been outlined by Stephens EH et al. (10) . Many CHD patients have excellent prognoses, if they receive operative intervention in a timely fashion. Identifying which patients are most likely to benefit from intervention, either from a minimal intervention with maximal benefit or those who are most likely to suffer significantly from delayed care must be prioritized.

The effect of pandemics and viral outbreaks on vulnerable pediatric patients has been previously demonstrated. In 2003, during a SARS outbreak in Canada, two hospitals in Toronto attempted to follow neonatal patients via mail/telephone surveys for a 2-month period during lockdown.

Compared to standard clinical practice for a similar 2 months period in 2005, approximately 25% of the neonates during the SARS period were lost to follow up, compared to a 7% rate during normal clinical operations (12) . A review of countries affected by the Ebola outbreak in 2014 to 2015, when access to healthcare decreased by an estimated 50%, showed significantly increased mortality from malaria, HIV/AIDS, and tuberculosis (13) . In one particular model, it was estimated that children < 5 years of age had a 50% higher mortality rate from untreated malaria during the Ebola outbreak (13) .

Finally, COVID-19 testing has been woefully lacking in the United States and worldwide as well as adequate PPE. Congenital cardiac programs are inherently small and especially vulnerable if providers are repurposed to COVID units. There is a limited pool of physicians with expertise in the care of CHD patients. Egypt is particularly vulnerable with about 250 pediatric cardiologist and 60 pediatric cardiac surgeons serving the 102 million citizens. It is paramount for each program to reduce overall exposure by scheduling providers in on/off rotations, maintaining adequate PPE, surveillance via widespread testing of asymptomatic health care providers and strategies for remote telehealth (10).

A triage system of care and a recommitment to the care of CHD patients must be implemented, or the death toll from COVID-19 will continue to mount through the loss of life from these hidden victims in the pandemic. The COVID-19 pandemic could last up to 2 years. Patients with CHD cannot wait until the pandemic has resolved to receive care. While it is not yet known how many CHD patients may be lost to follow-up or delay needed testing or intervention because of COVID-19, we can begin to mitigate this risk by reaching out to patients and families now and acting together regionally and globally. A 2018 review demonstrated that low income countries and low middle income countries already had a significant lack of access to cardiac surgery, resulting in premature death from rheumatic heart disease and congenital heart disease (14) . While we must be mindful of our patients' safety and protect them and their families from COVID-19 infection, the healthcare system must continue to care for those whose lives will be lost without intervention.

Countries such as Egypt, and even high income countries such as the United States where care for chronic diseases has also been halted, must find ways to care for CHD patients even in crisis. The international progress made in caring for CHD patients over the past 3 decades must not be lost.

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