The developed world is currently facing what seems to be a watershed, and no doubt one of the significant landmarks in the history of medicine. One of the greatest challenges of the medical community is the scarcity of knowledge and experience in facing this virus. (2-3)
Apart from the common typical viral symptoms (i.e. fever, cough, fatigue, dyspnea, and diarrhea) or, in more severe cases, pneumonia and ARDS, COVID-19 also has some significant consequences on the cardiovascular system and the management of cardiovascular patients. The first association between COVID-19 and the cardiovascular system is the increased risk in patients with pre-existing cardiovascular disease to develop severe disease and death. Second, complications such as myocarditis (8-10) acute myocardial infarction (11), arrhythmias (9), thromboembolic events (12-14), and heart failure(11,14), have been linked to COVID-19 infection. In some cases, these complications engendered treatment with ECMO (15-17). Third, reports on cardiovascular side effects of COVID-19 therapies have been published (18-20), and lastly, the pandemic’s consequences regarding non-COVID-19 cardiovascular patients. New policies have affected virtually each and every medical discipline, specifically those of surgeons in various fields who were required to apply a triage never before seen in their daily routine practice (3,6,7). Meanwhile, increasing numbers of patients are avoiding medical care while being symptomatic at home. As the pandemic is still ongoing, the aftermath remains largely unclear, with emerging reports of patients deteriorating or dying at home. However, it will be difficult to quantify the impact of non-COVID-19 morbidity and mortality during the COVID-19 pandemic. While the number of infected patients is objectively quantifiable, the number of non-COVID-19 patients suffering from the outbreak’s consequences is far from being measurable. In other words, the impact of the virus is not solely from personally transmitted infection.
One of the aspects of this may be illustrated in the field of cardiac surgery. At the beginning of the outbreak, Légaréet al., on behalf of the Canadian Society of Cardiac Surgeons (CSCS), released a guidance statement to cardiac surgeons. They suggested a template for triaging patients based on the percentage in reduction of services. According to their suggestion, upon a mild reduction in services (0-30%), only symptomatic outpatients or those at greater risk for developing adverse events, should undergo surgery alongside the urgent cases. Under a >50% reduction in services, they suggested operating on urgent cases only (4,7).
Israel was one of the first responders to the crisis, and consequently there has been a significant reduction in the number of cardiac surgeries performed. Evidently, characterizing the preoperative status of the entire patient cohort, those of the COVID-19 era were not necessarily sicker, but rather more symptomatic. Coincidentally or not, this correlates with the CSCS recommendation, although no guidance statement has been released by the Israel Society of Cardiothoracic Surgery. Apart from the obvious reasons, another consideration advocating for the delay of asymptomatic elective cases is the incubation period of COVID-19. A recent paper reported on patients who tested negative for COVID-19 during their asymptomatic incubation period and then underwent various surgical procedures. The mortality rate of these patients was dramatically high (20.5%) (21). Conversely, it could be argued that symptoms are subjective rather than objective parameters, and there might be some clinical discrepancies between NYHA and the severity of the disease.
One of the most intriguing facts demonstrated by this study emerged from the operative data. While there was no net difference in terms of types and complexity of procedures, patients from the COVID-19 era had longer procedural time. It could be that the cases selected in 2020 were more complex and challenging. However, it is difficult to ascertain whether the underlying reason for this is a more complex anatomy, late hospital arrival, or simply a coincidence.
Several factors may contribute to the higher rate of in-hospital mortality for patients in the 2020 group (13% vs. 5.2%). The first is the aforementioned assumption of more challenging procedures. The second hypothesis is possibly related to late hospital arrival of patients during the COVID-19 pandemic, which may have worsened their underlying condition. With the pandemic progressing worldwide, panic grew within the population, and indeed patients avoided hospitals even at the cost of being symptomatic.
Lastly, cardiopulmonary bypass might have a deleterious effect on COVID-19 patients undergoing cardiac surgery. This is explained by an increased inflammatory response triggered by the non-endothelial surfaces of the pump (22). However, as off-pump CABG is not routinely performed in our institute, this study was unable to evaluate a comparison between this possible effect of on-pump CABG.
May 2020 was a positive turning point in Israel concerning COVID-19. The “curve” seemed to be flattened and the number of new positive cases declined daily, together with the governmental restrictions including those concerning medical practices. This prompted the question of when to restore the daily routine in the field of interventional cardiology and cardiac surgery. In fact, the number of patients is growing on a daily basis and elective cases are now performed routinely. The safety of the medical teams remains the first priority, and the primary goal is to proactively manage all surgical cases including comprehensive COVID-19 screening protocol for both patients and personnel.
Now that the first major outbreak of COVID-19 seems to be fading away, cardiac surgeons must bear in mind that a second outbreak might be coming soon. Therefore, it is imperative that cardiac surgery teams should be vigilant and learn from their own experience and the experience of others. It is a call for surgeons to be aware of the possible and probable impact of COVID-19 on non-COVID-19 patients.