Cardiac surgery in the time of the coronavirus

Abstract

The current Covid‐19 pandemic is a significant global health threat. The outbreak has profoundly affected all healthcare professionals, including heart surgeons. To adapt to these exceptional circumstances, cardiac surgeons had to change their practice significantly. We herein discuss the challenges and broad implications of the Covid‐19 pandemic from the perspective of the heart surgeons.

Full text

J Card Surg. 2020;35:1177–1179. wileyonlinelibrary.com/journal/jocs
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DOI: 10.1111/jocs.14580
INVITED COMMENTARY
Cardiac surgery in the time of the coronavirus
Daniel P. Fudulu PhD |Gianni D. Angelini MD
Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
Correspondence
Daniel P. Fudulu, Department of Cardiac
Surgery, Bristol Heart Institute, Bristol BS2
8HW, UK.
Email: daniel.fudulu@bristol.ac.uk
Abstract
The current Covid‐19 pandemic is a significant global health threat. The outbreak
has profoundly affected all healthcare professionals, including heart surgeons. To
adapt to these exceptional circumstances, cardiac surgeons had to change their
practice significantly. We herein discuss the challenges and broad implications of the
Covid‐19 pandemic from the perspective of the heart surgeons.
KEYWORDS
cardiac surgery, coronavirus, Covid‐19 disease, pandemic, SARS Covid‐19
As of April 10, 2020, there are a total of 1 521252 confirmed cases
of Coronavirus Disease 2019 (Covid‐19), including 92 798 deaths
reported to WHO.
1
The pandemic has affected more than
190 countries around the world.
2
Described initially as a pneumonia
of unknown cause
3
that was detected in Wuhan City, Hubei Province
of China, in December 2019, the SARS Covid‐19 virus outbreak is
now a global health threat with profound social and professional
implications. Due to its effective transmission, more than a third of
the global population is currently in lockdown as part of a mitigation
strategy that aims to reduce the capacity of the virus to kill by in-
creasing the ability of the health services to cope with the surge in
cases.
4
Some of us might have thought that cardiac surgeons will not be
in the Covid‐19 battle frontline. However, due to the magnitude of
this pandemic, we are all in this together. Therefore, many cardiac
surgeons are now facing an abrupt change to their daily practice and
even in their speciality theme. Somehow, we now have to forget that
we operate on hearts for a living. We now have to understand that
we are first doctors then surgeons. At the peak of this crisis, many
cardiac surgeons find themselves working in Covid‐19 critical care
units or wards, and some volunteer to cover critical care nurse roles.
It is an apocalyptic scenario that no one would have imagined a few
months ago. Identifying ourselves as Covid‐19 doctors rather than
cardiac surgeons can be very satisfying and meaningful. However,
this comes with the anxiety of contracting the virus and potentially
spreading it to our families. Sadly, doctors, including cardiac sur-
geons
5
died from the coronavirus, and many others will likely lose the
battle with the virus in the future.
Furthermore, the lack of adequate personal protective equip-
ment (PPE) that was reported in many parts of the world, staff ab-
sences due to sickness or isolation can further exacerbate this
anxiety and work pressure. The current lack of a reliable antibody
test for medical staff does not provide the certainty that we are
immune to the virus and provides no reassurance when we are sent
in the frontline. Some of us might feel strong and with no risk factors,
thus capable of mounting an adequate response. While the statistics
show that the mortality is higher in older patients or with underlying
conditions,
6
it is worrying that we do not fully understand the im-
mune susceptibility to develop the severe form of the disease that
continues to be reported in some young and fit individuals. As
healthcare workers, we are likely to be exposed to a higher viral load
that can be associated with developing more severe forms of the
disease.
7
We are now part of a single team in the face of a viral tsunami.
This can be very challenging and will put to the test our team player
abilities. However, due to the unique leadership skills, stamina and
determination within our speciality, we can rightly consider cardiac
surgeons as elite troops working in exceptional circumstances.
Hospitals throughout the world had to increase their critical care
bed capacity manyfold, and most of the elective cardiac surgery
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© 2020 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals, Inc.

operations have now been postponed. In a very short time, large field
hospitals are being built in the conference venues where we used to
present our scientific work. Our cardiac theatre rooms are being
transformed into critical care wards. Amid these unprecedented, step‐
wise escalation plans,
8,9
we have to make difficult decisions about
which patients we consider urgent? Most cardiac surgery units limit
surgery to cases such as aortic dissection in the young patient,
emergency coronary artery by‐pass not amenable to percutaneous
coronary intervention or valve surgery not amendable to transcath-
eter aortic valve replacement. While some scenarios can be straight-
forward, in other cases, it is hard to ascertain which patients can be
deferred and for how long? Moreover, we also have to weigh the risk
of inpatient Covid‐19 infection against the risk of delaying the surgery.
To achieve a very reduced length of stay, we are now diverting a
significant proportion of the urgent cases to interventional cardiol-
ogy. However, how optimal are the long‐term outcomes of these
percutaneous cases that were meant to be treated surgically? Once
we suppress this pandemic and we return to full capacity, how are we
going to deal with this considerable pool of patients with delayed
procedures? This is likely to require a significant effort and planning
and will likely result in increased collateral mortality.
A new challenge is operating on patients that are Covid‐19 po-
sitive or suspected as high risk for the disease. Therefore, to mitigate
the infectious risk, we must cope with wearing special PPE during
cardiac procedures and adhere to specific theatre protocols. We also
have to respect designated hospital zones that aim to limit inpatient
transfers to contaminated areas and be vigilant to assess and screen
patients for Covid‐19 before transfer from peripheral hospitals.
Covid‐19 outbreak has completely reshaped the way we do cardiac
surgery in a matter of months.
Undoubtedly, this pandemic will be a catalyst for the rapid de-
velopment and retainment of telemedicine. One example is that most
of our follow‐up clinics are now run by video or telephone call. Run-
ning these clinics might be challenging since most of us are used to a
physical, patient consultation. Similarly, multidisciplinary meetings and
mortality and morbidity meetings are set up in a virtual space.
The volume of operating has reduced dramatically and is now
limited to specific pathologies. Some cardiac surgeons might deskill
during this process. Furthermore, most of the cardiothoracic training
programme are now put on hold throughout the world, and there is
no access to scientific conferences or exams. Once the Covid‐19 dust
settles, cardiac surgeons will have to regain this lost ground.
We are dealing with a new disease in our cardiac surgical
patients, and we have no understanding of it. There is no research
into short term and long term outcomes of patients undergoing
cardiac surgery that are Covid‐19 positive. Several studies are un-
derway for the surgical population in general,
10
and likely more
studies are warranted in the cardiac surgery subgroup. However,
we are likely dealing with a very vulnerable patient population due to
the underlying cardiovascular disease that is associated with high
mortality in Covid‐19 disease.
11
Patient care should always be our primary focus; however, we
also have to be aware of the current economic shutdown that will
affect the jobs in our speciality and the resources available to treat
our patients.
At the time of writing, the future is uncertain, and we have no clear
exit strategy. Social distancing is a short term and effective solution to
increasing our critical care bed capacity and to reducing the spread of
the virus.
4,6
After we flatten the curve, when and how do we relax these
restrictive measures to avoid a second wave of infection is unknown.
Certainly lifting such restrictions prematurely could result in the so‐
called “double‐humped curves”we have seen in the H1N1 (Spanish flu)
pandemic 1918.
12,13
In 2020, we are in a better position, and we can
use sophisticated epidemiological modelling to inform policy decisions.
4
There is no consensus on the best therapeutic strategy for Covid‐19
disease, and the current treatment is mainly supportive.
Nevertheless, we know how to develop vaccines and have many
pharmacological strategies in our armamentarium. There is an on-
going research effort underway to evaluate various pharmacological
agents including antiviral medication, chloroquine, Chinese medicine
products, monoclonal antibodies, and intravenous hyperimmune
globulin from recovered persons.
6
There is a hope for the develop-
ment of a vaccine that could be crucial in the suppression of the
outbreak. Two vaccines are in clinical evaluation and 60 more in
preclinical evaluation phase.
14
However, this race is estimated to
take at least 12 to 18 months.
15
For now, we might have to live and work in the Covid‐19 pan-
demic. By working together and remaining resilient, we will return to
our normal lives and to our speciality—cardiac surgery where lots of
work will be expecting for us.
ACKNOWLEDGEMENTS
This study was supported by the NIHR Biomedical Research Centre
at University Hospitals Bristol NHS Foundation Trust, the University
of Bristol and Bristol Heart Foundation (CH/1992027/7163 to
Gianni Angelini). The views expressed in this publication are those of
the authors and not necessarily those of the NHS, the National
Institute for Health Research or the Department of Health and Social
Care. The funder paid the salaries of researchers and the consum-
ables of the project. It had no part in the scientific methods used in
the study and plaid no part in the research.
AUTHOR CONTRIBUTIONS
DPF and GDA: (a) Substantial contributions to research design, or the
acquisition, analysis or interpretation of data; (b) drafting the paper
or revising it critically; and (c) approval of the submitted and final
versions.
ORCID
Gianni D. Angelini http://orcid.org/0000-0002-1753-3730
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How to cite this article: Fudulu DP, Angelini GD. Cardiac
surgery in the time of the coronavirus. J Card Surg. 2020;35:
1177–1179. https://doi.org/10.1111/jocs.14580
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