key: cord-0906431-yat4wn19
authors: Khalil, Kalil Hussein; Sá, Michel Pompeu B. O.; Vervoort, Dominique; Roever, Leonardo; Pires, Marcos Alfredo de Andrade; Lima, Jaqueline Maria de Oliveira; de Salles, Felipe Borsu; Khalil, Giovana Munhoz; Nicz, Pedro Felipe Gomes; Mejía, Omar Asdrúbal Vilca; Okino, Arnaldo Akio; Lima, Ricardo de Carvalho
title: Impact of the COVID‐19 pandemic on coronary artery bypass graft surgery in Brazil: A nationwide perspective
date: 2021-06-20
journal: J Card Surg
DOI: 10.1111/jocs.15765
sha: 8adc323a50fe4fc1a70c9b59a35e3ea3f0e4fb9b
doc_id: 906431
cord_uid: yat4wn19

INTRODUCTION: The coronavirus disease 2019 (COVID‐19) pandemic has been a worldwide challenge, and efforts to “flatten the curve,” including restrictions imposed by policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. The aim of this study is to evaluate the outcomes of coronary artery bypass graft (CABG) from 2008 to 2020 in the SUS and to assess the impacts of the COVID‐19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS. METHODS: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures and death rates. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. RESULTS: We identified 281,760 CABG procedures performed from January 2008 to December 2020. The average number of procedures until the end of 2019 was of 22,104. During 2020 there was a 25% reduction CABG procedures, to 16,501. There was an increase in the national death rate caused by a statistical significant increase in death rates in Brazil's Southeast and Central‐west regions. CONCLUSION: The COVID‐19 pandemic remains a global challenge for Brazil's health care system. During the year of 2020 there was a reduction in access to CABG related to an increase in the number of COVID‐19 cases. There was also an increase in the national CABG death rate.

The coronavirus disease 2019 (COVID-19) pandemic has affected more than 113 million people and caused more than 2.5 million deaths as of February 2021. 1 Brazil is a country of continental dimensions with significant differences in climate, genetic ancestry and lifestyle across its distinct regions. It occupies 47% of South America's area, mainly in the tropical region, and has more than 200 million inhabitants. 2 More than 10 million Brazilians have been infected by the virus that causes COVID-19, with more than 250 thousand deaths. 3 The pandemic has been a worldwide challenge. Efforts to "flatten the curve" and keep hospital beds and intensive care units available for COVID-19 patients, along with the restrictions imposed by Brazilian policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. 4 Recently, the outcomes of coronary artery bypass graft (CABG) in the Brazilian public health system (SUS) from January 2008 to December 2017 have been published. 5 The aim of this study is to evaluate the outcomes of CABG over the next years (2018 to 2020) in the SUS and to assess the impacts of the COVID-19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS.

The material was obtained from DATASUS, the data processing system of the Brazilian Ministry of Health, which collects information from every patient who needs in-hospital care and was admitted to a public hospital, gathering and auditing data with relation to number of surgical procedures, death rates and costs.

DATASUS encompasses the Hospital Information System (SIH) as one of its elements. The SIH is based on filling out the Hospital Admission Authorization Form. SUS/SIH resorts to a codification system for every surgical procedure. The current codes for CABG are 0406010927, 04060010935, 0406010943, and 0406010951. All isolated CABG procedures performed in the public health care system were included in our study, regardless of the hospital or city and whether they were on-pump 

The χ 2 test was used to compare death rates. Odds ratio and 95% CABG procedures, to 16,501 (see Table 1 ). There was an increase in the national death rate caused by a statistical significant raise in death rates from the Southeast and Central-West regions. Nearly all of the decrease in case volume over the study time frame occurred in the Southeast Region. The Southeast was responsible for almost 50% of CABG surgeries. Together, the Southeast and South were responsible for almost 75% of all surgeries (see Figure 1C ).

February 2020 and the fist death reported in the middle of March 2020. By the end of March over 4500 cases had been diagnosed, and policymakers and medical societies were beginning to raise the red flag. Figure 2A shows the COVID-19 new cases and deaths by day of notification. Clearly, as the cases of COVID-19 began increasing during March, the number of CABG decreased as surgeons needed to postpone elective procedures (see Figure 2B ). By August the number of cases and deaths had begun to decrease and as hospital beds and intensive care units (ICUs) were becoming available the number of procedures increased again. Interestingly, during the South region increased its volume of surgeries in 2020 by 5%, probably affected by the number of procedures performed in the Southeast (see Figure 2C ).

The COVID-19 pandemic has been one of the great challenges of the medical community and for health care policymakers. In Israel there was a decline in patients undergoing cardiac surgery and an increase in surgical death rate. 7 The daily routines of society, world economy and practice of cardiac surgeons has changed. 8 It is well established that the extracorporeal circulation generates a systemic inflammatory response syndrome and that severe acute respiratory syndrome (SARS) from COVID-19 may lead to "cytokine storm" resulting in shock and death, as reported by a cardiovascular division in Italy. 9, 10 It has been reported that patients who underwent cardiac surgery during 2020 have been infected with COVID-19, and that patients with CVD are more likely to have a severe presentation of SARS from COVID-19. 11 Another major concern is that patients with CVD disease are afraid to call emergency assistance or go to emergency rooms for fear of contracting COVID-19 or burdening an already-overwhelmed health-care system. 12 One possible explanation to the increase in death rate is that in most of the time only emergency surgeries were allowed, characterizing more severe patients.

Our institution is a regional hospital in the north of the state of Parana. It provides health care for more 150 cities in Parana, in the There are no data on the outcomes in patients who had postponed surgeries. There also are no data on the clinical outcomes of patients submitted to CABG who became infected with COVID-19 during perioperative care, which could be a contributing factor to the increase in death rate.

COVID-19 remains a worldwide challenge for the health care system.

During the 2020 there was a reduction in access to CABG related to an increase in the number of COVID-19 cases. There was also an increase in the national CABG death rate compared with the last decade.

The authors declare that there are no conflict of interests. 

Johns Hopkins Coronavirus Resource Center

Ten weeks to crush the curve

Coronary artery bypass graft surgery in Brazil from 2008 to 2017

The impact of COVID-19 pandemic on cardiac surgery in Israel

COVID-19: general guidelines for cardiovascular surgeons (standard guidelines-subject to change)

Cardiac surgery outcomes in patients with coronavirus disease 2019 (COVID-19): a case-series report

Coronary artery bypass graft during the COVID-19 pandemic

Implications of the COVID-19 pandemic for cardiovascular disease and risk factor management

Impact of the COVID-19 pandemic on coronary artery bypass graft surgery in Brazil: A nationwide perspective