key: cord-1053282-m3c4shni authors: Omar, Amr Salah; Shoman, Bassam; Sudarsanan, Suraj; Shouman, Yasser title: Chest radiography requirements for patients with asymptomatic COVID-19 undergoing coronary artery bypass surgery: Three case reports date: 2021-05-25 journal: World J Virol DOI: 10.5501/wjv.v10.i3.130 sha: 5e387aea0b84d72fc732adf40348569f11a5bb73 doc_id: 1053282 cord_uid: m3c4shni BACKGROUND: The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2, represents a major challenge to health care systems both globally and regionally, with many opting by cancelling elective surgeries. Cardiac operations in patients diagnosed with COVID-19 have been imperative due to their emergency nature, critical condition of patients awaiting cardiac surgery, and accumulated number of cardiac surgical interventions throughout the last months. CASE SUMMARY: Here we describe three COVID-19 positive cases who underwent coronary surgery, on an urgent basis. We did not experience worsening of the patients’ clinical condition due to COVID-19 and therefore a routine post-operative chest X-ray (CXR) was not required. None of the health care providers attending the patients endured cross infection. Further trials would be needed in order to confirm these results. CONCLUSION: While the pandemic has adversely hit the health systems worldwide, cardiac surgical patients who concomitantly contracted COVID-19 may undergo a smooth post-operative course as a routine post-operative CXR may not be required. performed the concept, writing and manuscript revision; Shoman B performed the study design, contribution to the concepts and revising the final form; Sudarsanan S performed the data management and manuscript revision; Shouman Y performed the critical revision and cases review; all authors read and approved the final manuscript. Corporation. Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment. This study was approved by medical research center in Hamad Medical Corporation. The ethical committee in Hamad medical corporation approved the study (reference number MRC 04-20-586), all study data were maintained anonymously. The World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) as a global pandemic in March 2020, after the disease swept across the world from its epicenter in Wuhan, China. The disease represented a major challenge for the public and healthcare community globally [1] . The pandemic overwhelmed the health systems, forcing major changes in the health care practices [2] . Under the pressure from acute bed shortage, many health care facilities opted to defer elective surgical procedures[3], consequently, cardiac surgery elective services were forced to be canceled or postponed [4] . Shoman et al [5] reported that urgent cardiac in patients with COVID-19 without pneumonia could be carried out safely without further complications or health care associated cross infection, if strict infection control protocols would be enforced during the procedure [5] . The explosive and uncontrolled spread of COVID-19 globally made it imperative for the cardiac surgery societies to release guidelines and protocols aiming to risk assess protocols based on probabilities and resources [6] . Here we describe three COVID-19 positive cases, with no pulmonary-related symptoms, diagnosed with significant coronary artery disease and subsequently subjected to urgent coronary surgery. This manuscript also sheds light on the role of routine chest radiology in perioperative management. Case 1: A 43-year-old gentleman was presented to the hospital with recent onset chest pain. A 50-year-old gentleman was presented to the emergency cardiac department with acute onset of severe chest pain. Case 1: The patient's 12-lead electrocardiogram (ECG) indicated a non-ST segment elevation myocardial infarction (NSTEMI). Subsequent coronary angiography revealed critical left main coronary artery distal occlusion with additional three vessels coronary artery disease (CAD), all of which were severely occluded. Case 1: Patient's post-operative course in the CTICU was uneventful, after removal of the chest drain patient was discharged to the dedicated COVID-19 high dependency unit within the hospital for a short stay, in order to optimize COVID treatment. Patient was subsequently discharged home on the seventh post-operative day. The patient remained in the unit until removal of the chest drain and then transferred to the dedicated isolation ward in the hospital. Later, the patient was discharged home for self-quarantine, on the eight post-operative day, and subsequently followed up by routine telephonic consultation without any reported surgical complications. Case 3: Patient was extubated on the same operative day in the CTICU and transferred to an isolation room on the ward in the first post-operative day, where cardiac rehabilitation was completed. Patient was then discharged for self-quarantine for 14 d. No chest radiography was required in the aforementioned three patients (Table 1 ). The challenge of handling urgent surgeries alongside COVID-19 diagnosis is of limited familiarity amongst practitioners. Decision making and risk assessment protocols can define COVID-19's influence on cardiothoracic surgical outcomes. The three patients here referred are examples of patients who had been through pragmatic decision making protocols to perform such surgeries. The apparent medical stability of these patients, from a respiratory standpoint, encouraged our team to act towards treating the patient's acute coronary syndrome, reducing possible related mortality and morbidity. Anticipating the need to operate COVID-19 patients, our department developed a protocol for perioperative management of COVID-19 patients undergoing cardiac surgery, which was reviewed by all stakeholders. Furthermore, our team followed patients with COVID-19 after cardiac surgery with a chest radiology when clinically indicated as per the CTICU protocol. This was successfully carried out for all three patients here reported, without any significant clinical issue compromising the patient's outcome. Reducing unnecessary chest radiology is a widely agreed goal in the post-operative care of patients after cardiac surgery. Tolsma et al [7] made an observational study with 1102 patients aiming to define clear indications for chest X-ray (CXR) after cardiac surgery. This practice was safe and effective in reducing the total number of CXRs performed and also anticipated increased efficacy [7] . Similarly, Forouzannia et al [8] reviewed 118 patients who underwent off pump coronary surgeries and their postoperative outcome did not change when CXR were eliminated in the post-operative period [8] . In our organization, we have defined certain criteria for chest radiography during post-operative cardiac surgical care. This included clinical evaluation-based findings of fever, dyspnea, abnormal pulmonary sounds, signs and symptoms of cardiac tamponade, abnormal chest tube bleed or air leak, and doubtful position of endodontically treated teeth and vascular lines. Hypoxia on pulse oximeter (SaO 2 < 92% on regular oxygen therapy) and multiple punctures during central venous access also mandated CXR. A final clinical evaluation focused on X-ray findings. All patients were discharged 5-7 d after surgery. A 30-d follow-up included at least two visits. Patients were in constant contact with the cardiac clinic. Symptomatic patients were selectively re-examined to rule out complications. In our tertiary center, we have set up a multidisciplinary team approach before deciding to surgically operate on COVID-19 positive patients. This team involved anesthesiologists, cardiac surgeons, cardiologists, and infectious diseases specialists. Asymptomatic but serologically positive COVID-19 patients underwent management as actively infectious. To all these patients the used of full PPE was mandatory [9] . The coronary lesions' anatomical complexity in all three patients here studied were treated as meaningful and consequently conceived to be subjected to operation. Significant left main disease or acute coronary syndrome not amenable to percutaneous intervention Most cardiac cardiothoracic centers practice CXR in the immediate post-operative period routinely, in absence of any clinical or laboratory indication. However, the accuracy of CXR in diagnosing pulmonary opacities in the post-operative period is limited and its accuracy in visualizing and defining etiology of pulmonary opacity is moderate [11] . Moreover, management may not be changed in response to abnormal CXR findings [12] . The risks associated with radiation exposure, manpower wastage, cost incurred, possible displacement of invasive line, and endotracheal tubes are additional concerns [13] . We appealed the CTICU team to be present at the operating theatre door for receiving the patient and to minimize practitioners' transportability of a possibly contaminated PPE. Patient's transfer to the CTICU after surgery was carried out with a transport ventilator and minimal essential team comprised of a single respiratory therapist, nurse, and physician. Patel et al [14] emphasized the value of minimal ventilator circuit interruption, reducing practitioners' presence and unnecessary ventilator transport [14] . The same principles applied when attempting to do CXRs. The patient's preparation before transport to ICU, by covering the patient with a plastic sheet and connecting them to a portable ventilator, was done after clamping/ de-clamping technique. Patient's escorting to the isolation room of the CTICU was done by the ICU team which comprised a physician, nurse, and respiratory therapist. Doffing of the anesthesia team was done in a pre-designated area in the operation theatre. The operation room was disinfected thereof and restricted until the following morning. The protocol for managing COVID-19 positive patients was followed by the anesthesia team. The safety of patients transported to and from the theatres needs to be customized for each hospital, considering the basic principles of minimizing exposure and maximizing communication [15] . We have transferred COVID-19 positive patients to a COVID ICU unit enclosing negative-pressure rooms with additional high-efficiency particulate air filters. We have also taken into account early possible surgical complications such as arrhythmias, myocardial injury, acute renal injury, and the respiratory complications [16, 17] . None of our three patients showed early cardiac or respiratory complications and all were able to be transferred from ICU after a median of 24 h after surgery. While the pandemic adversely has hit the health systems worldwide, cardiac surgical patients who concomitantly contracted COVID-19 infection may undergo a smooth post-operative course as a routine post-operative CXR may not be required. 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Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons Interobserver variability in applying a radiographic definition for ARDS Pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features Utility of routine chest radiographs in a medical-surgical intensive care unit: a quality assurance survey Cardiac Surgery During the Coronavirus Disease 2019 Pandemic: Perioperative Considerations and Triage Recommendations CMS Adult Elective Surgery and Procedures Recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic This work would not have been possible without the kind support and help of many individuals and our organization. The authors thank all members of the Cardiothoracic surgery department, Heart Hospital, of Hamad Medical Corporation, Qatar, for extensive work during this hard time and for providing the required data. The authors also thank the members of the medical research department of Hamad Medical Corporation for their support throughout this project.