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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.
J Card Surg. 2020;35:11771179. wileyonlinelibrary.com/journal/jocs
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1177
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 Covid19 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
Covid19 pandemic from the perspective of the heart surgeons.
KEYWORDS
cardiac surgery, coronavirus, Covid19 disease, pandemic, SARS Covid19
As of April 10, 2020, there are a total of 1 521252 confirmed cases
of Coronavirus Disease 2019 (Covid19), 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 Covid19 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 Covid19 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 Covid19 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 Covid19 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 bypass 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 Covid19 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 longterm 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 Covid19 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 Covid19 before transfer from peripheral hospitals.
Covid19 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 followup 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 Covid19 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 Covid19 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 Covid19 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 doublehumped curveswe 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 Covid19
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 Covid19 pan-
demic. By working together and remaining resilient, we will return to
our normal lives and to our specialitycardiac 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:
11771179. https://doi.org/10.1111/jocs.14580
FUDULU AND ANGELINI
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... 23 Doctors, including cardiac surgeons, have also died due to the coronavirus. 24 Lack of enough PPE, and absences due to illness or isolation can further aggravate work pressure. The availability of hospital beds has been limited, and ICUs have collapsed because of the massive influx of patients with severe pulmonary disease. ...
... Most cardiac surgeries are confined to cases such as aortic dissection, emergency coronary artery bypass not amenable to percutaneous coronary intervention (PCI), or valve surgery unamendable to trans catheter aortic valve replacement. 24 In North America, nonurgent surgery was stopped during March 2020 in 96% of health centers resulting in a drop to 45% of baseline. As a ratio of total surgical volume, there was a relative rise in coronary artery bypass grafting surgery, ECMO, and heart transplantation, and a drop in valvular cases. ...
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Cardiac surgery was severely affected by the COVID‐19 pandemic. Reallocation of resources, conversion of surgical intensive care units and wards to COVID‐19 facilities, increased risk of nosocomial transmission to cardiac surgery patients, lead to reduced accessibility, quality, and affordability of health care facilities to cardiac surgery patients. Increasing the mortality and morbidity rate among such patients. Cardiac patients are at an increased risk to develop a severe illness if infected by COVID‐19 and are associated with a high mortality rate. Therefore, measures had to be taken to reduce the spread of the virus. Various approaches such as the hubs and the spokes centers, or parallel system were enforced. Elective surgeries were postponed while urgent surgeries were prioritized. Use of personal protective equipments and surgeries performed by only senior surgeons became necessary. Surgical trainees were also affected as limited training opportunities deprived them of the experience required to complete their fellowship. Some of the trainees were reallocated to COVID‐19 wards, while others invested their time in research opportunities. Online platforms were used for teaching, meetings, and workshops across the globe. Although some efforts have been made to reduce the impact of the pandemic, more research and innovation is required.
... Cardiovascular surgery centers were converted into COVID-19 facilities in significant quantities. A significant decrease in the number of surgical cases has been observed as a result [5] . Due to the involvement of the respiratory tract, COVID-19 may be fatal and may serve as a significant contraindication to surgery, unless emergent severe conditions (e.g., acute aortic dissection) occur [6] . ...
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Background: Worldwide, cardiac surgery has been significantly impacted by the COVID-19 pandemic infection. In the event of respiratory tract involvement, COVID-19 may be fatal and may serve as a significant contraindication to surgery. Our objective was to investigate the safety and outcomes of patients who underwent cardiac surgeries subsequent to their COVID-19 infection. Methods: This retrospective observational study was carried out on 22 patients undergoing elective or urgent open-heart surgery following COVID-19 infection. Results: 9 patients (40.91%) were extubated within 24 hours of surgery, 6 patients (27.27%) were extubated on the first postoperative day, and 3 patients (13.64%) were extubated on the second postoperative day. Regarding the postoperative complications, 6 (27.27%) patients required NIV with a mean ± SD of duration 6 ± 2.37 days (range 3-9 days), and 5 (22.73%) developed respiratory failure, 2 (9.09%) developed heart failure, 1 (4.55%) patient experienced AKI on pre-existing CKD, and 1 (4.55%) patient developed dilated cardiomyopathy was presenting with CAD + VHD. 3 (13.64%) patients needed inotropes, one of them developed dilated cardiomyopathy and the other two developed heart failure.
... Our CTVS department which was operating more than 1100 cases per year before the Corona era has come down to 232 cases of open heart surgery only. Same status was also noted by (3 Fudula DP et al in their study ) with potential negative impact to the community. ...
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Background A sudden emergence of global pandemic due to SARS- Cov -2 has changed the scenario of management of non COVID diseases. With very high infectivity rate and stormy course, this disease has made the lives of people miserable so with the health care facilities and treatment. All the medical fraternities are in the state of confusion that how to treat or not to treat the patients of illness other than the corona virus infection. We are sharing our experience of cardiac surgery at our tertiary center in lockdown and unlockdown period. Material And Method This is a retrospective study from April 2020 to November 2020. We have operated upon 232 cases in this duration. Results Out of 232 cases – Overall mortality –26, Post covid operated – 4, Number of covid positive after surgery – 3, Post covid mortality – 1 Conclusion Use of N95 mask, PPE kit or HIV KIT, with regular sanitization of hands have made possible to perform cardiac surgery in this difcult situation on the patients of cardiac illness which usually cannot wait longer.
... Many cardiac surgeons have had to change their daily practice, with some offering their services in critical care units to meet the demand caused by the pandemic. 64 Not only have these placed surgeons into an unfamiliar environment, but the pandemicassociated risks for healthcare workers contributes to an increased level of anxiety. Due to the redistribution of resources in many countries towards critical care services for patients suffering from COVID-19, cardiac surgical procedures have been frequently delayed. ...
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Introduction: The COVID-19 pandemic has had a significant impact on global surgery. In particular, deleterious effects of SARS-CoV-2 infection on the heart and cardiovascular system have been described. To inform surgical patients, we performed a systematic review and meta-analysis aiming to characterize outcomes of COVID-19 positive patients undergoing cardiac surgery. Methods: The study protocol was registered with PROSPERO (CRD42021228533) and conformed with PRISMA 2020 and MOOSE guidelines. PubMed, Ovid MEDLINE and Web of Science were searched between 1 January 2019 to 24 February 2022 for studies reporting outcomes on COVID-19 positive patients undergoing cardiac surgery. Study screening, data extraction and risk of bias assessment were conducted in duplicate. Meta-analysis was conducted using a random-effects model where at least two studies had sufficient data for that variable. Results: Searches identified 4223 articles of which 18 studies were included with a total 44 patients undergoing cardiac surgery. Within these studies, 12 (66.7%) reported populations undergoing coronary artery bypass graft (CABG) surgery, three (16.7%) aortic valve replacements (AVR) and three (16.7%) aortic dissection repairs. Overall mean postoperative length of ICU stay was 3.39 (95% confidence interval (CI): 0.38, 6.39) and mean postoperative length of hospital stay was 17.88 (95% CI: 14.57, 21.19). Conclusion: This systematic review and meta-analysis investigated studies of limited quality which characterized cardiac surgery in COVID-19 positive patients and demonstrates that these patients have poor outcomes. Further issues to be explored are effects of COVID-19 on decision-making in cardiac surgery, and effects of COVID-19 on the cardiovascular system at a cellular level.
... Our study shows a positive correlation between anxiety level and the decision to seek medical care of non-COVID patients, which eventually results in deferring serious medical care. This observation could provide an additional explanation for the higher incidence of out-ofhospital cardiac arrest and higher mortality rate reported during the outbreak [32][33][34][35][36][37][38]. Our data is consistent with retrospective observational studies conducted outside of Israel [39,40]. ...
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... As well-known, besides the unprecedented impact of the COVID-19 worldwide pandemic with regard to patients experiencing a variety of clinical compromises due to the infective illness, lack of dedicated beds and equipment to face overwhelming hospital admittance for respiratory dysfunction, delay in hospital admission of patients with other illnesses, and reduced hospital activities for non-COVID-related treatments, were also described as severe consequences during the outbreak with inevitable suboptimal patient management. [1][2][3][4][5] Liu et al. have reported a single-center, retrospective, and comparative study looking at 2-year series of patients requiring surgical treatment for acute infective endocarditis (AIE) just prior to or just after the start of the COVID-19 pandemics. 6 The findings of this study clearly confirm that patients admitted with a suspicion of AIE had more critical cardiac as well as general clinical conditions at admittance during the pandemic. ...
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The COVID‐19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Liu et al. has clearly shown the higher risk features which patients with a diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with the worse outcome if compared to results obtained before the SARS‐2 pandemic. The report discussed herein presents several other aspects worth discussion and comments, particularly in relation to hospital management and postdischarge outcome which certainly deserve to be highlighted, but also further investigations.
... Within 6 months of the first case being detected more than 7,000 health care workers globally had died, 1,500 of whom were nurses [10]. Medical staff and indeed cardiac surgeons were not exempt from risk, volunteering in some instances to cover critical care nursing roles [11]. ...
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Introduction Coronavirus disease (COVID-19) caused by SARS-CoV-2 virus identified in 2019, forces cardiology departments to quickly adapt existing clinical guidelines to the new reality, and this is particularly relevant for scheduling patients with acute coronary syndrome (ACS). The article demonstrates how COVID-19 has affected emergency cardiac surgery care. Objective To analyze the features of completed cases of emergency coronary artery bypass grafting (ECABG) and COVID-19 diagnosed during the postoperative period at the Research Institute – Ochapovsky Regional Hospital no. 1 for the period from May 1, 2020 to February 1, 2021. Material and Methods Completed cases of ECABG have been retrospectively studied. EACS was performed in 145 patients: in 79 people with unstable angina pectoris (NS), in 40 with Q-negative myocardial infarction (MI), in 14 cases with primary Q-positive MI, in 12 patients with recurrent MI. The condition for ECABG was a negative SARS-Cov-2 PCR result and the absence of viral pneumonia by CT. The patients were divided into 2 subgroups. The first one included people with ECABG that were not diagnosed with COVID-19 during postoperative follow-up in the hospital. Subgroup II had patients with ECABG and COVID-19 diagnosed during the hospitalization. Results Contingency tables showed a statistically significant interaction between group membership and mortality, 2.3% (n = 3) in subgroup 1 and 20% (n = 3) in subgroup 2, Pearson’s test χ2 = 10.6, p < 0.05. When analyzing survival rate in the EACS + COVID-19 subgroup, it is worth paying attention to the cumulative proportion of survivors, considering the severity of the course of viral pneumonia. The proportion of such patients with CT-4 by the 32nd day of hospital stay was 0.3. Conclusions Mortality rate in the postoperative course after ECABG with COVID-19 is significantly higher. In patients who underwent ECABG and died in the early and late postoperative period from COVID-19, a new coronavirus infection was diagnosed at a later date. In these cases, a considerably longer duration of CPB and a higher level of ferritin were revealed at the time of transference to the observation department. Survival rate in ECABG patients due to primary Q-negative MI is significantly lower in comparison with patients hospitalized for unstable angina.
Chapter
The impact of COVID-19 on surgical disease has been transformative. The complete extent of its impact is unlikely to be fully understood for decades to come. New surgical disease processes, many still being elucidated, have emerged as both a direct result of COVID-19, as well as sequelae from the pathophysiologic response to the disease. The most notable consequences include hypercoagulability due to COVID-19 as well as a predilection for gastrointestinal tract pathology. The perioperative sequelae of the novel COVID-19 virus on surgical disease remain unknown, but evidence suggests this disease increases perioperative risk. Perhaps just as concerning, are the economic impacts and paradigm altering consequences that have been felt. Elective surgeries ground to a halt, trauma activations experienced sharp upswings and downswings, and visits to doctors in general have taken a sharp downturn. This has led to delays in diagnosis and treatment, increases in morbidity and mortality, and dramatic changes in how surgical services around the world are run. This global pandemic will forever change how surgery is practiced and shape our profession for decades to come.
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We noted that the DCt values of severe cases were significantly lower than those of mild cases at the time of admission (appendix). Nasopharyngeal swabs from both the left and right nasal cavities of the same patient were kept in a sample collection tube containing 3 mL of standard viral transport medium. All samples were collected according to WHO guidelines.5 The mean viral load of severe cases was around 60 times higher than that of mild cases, suggesting that higher viral loads might be associated with severe clinical outcomes. We further stratified these data according to the day of disease onset at the time of sampling. The DCt values of severe cases remained significantly lower for the first 12 days after onset than those of corresponding mild cases (figure A). We also studied serial samples from 21 mild and ten severe cases (figure B). Mild cases were found to have an early viral clearance, with 90% of these patients repeatedly testing negative on RT-PCR by day 10 post-onset. By contrast, all severe cases still tested positive at or beyond day 10 post-onset. Overall, our data indicate that, similar to SARS in 2002–03,6 patients with severe COVID-19 tend to have a high viral load and a long virus-shedding period. This finding suggests that the viral load of SARS-CoV-2 might be a useful marker for assessing disease severity and prognosis.
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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects host cells through ACE2 receptors, leading to coronavirus disease (COVID-19)-related pneumonia, while also causing acute myocardial injury and chronic damage to the cardiovascular system. Therefore, particular attention should be given to cardiovascular protection during treatment for COVID-19.
Coronavirus: 5 lessons on social distancing from the 1918 Spanish flu pandemic
  • Lopezg
Lopez G. Coronavirus: 5 lessons on social distancing from the 1918 Spanish flu pandemic. Vox. https://www.vox.com/policy-and-politics/ 2020/3/24/21188121/coronavirus-covid-19-social-distancing-1918-spanish-flu. Accessed April 11, 2020.
COVID-19 reports (Faculty of Medicine
  • N M Ferguson
  • D Laydon
  • G Nedjati-Gilani
Ferguson NM, Laydon D, Nedjati-Gilani G, et al. COVID-19 reports (Faculty of Medicine, Imperial College London). https://www.imperial. ac.uk/mrc-global-infectious-disease-analysis/news--wuhan-coronavirus/. Accessed March, 2020.
How they flattened the curve during the 1918 Spanish Flu
  • Strochlicn Champinerd
COVID-19 reports (Faculty of Medicine Imperial College London
  • Fergusonnm Laydond Nedjati-Gilanig
How they flattened the curve during the 1918 Spanish Flu
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  • R D Champine
Strochlic N, Champine RD. How they flattened the curve during the 1918 Spanish Flu. National Geographic. https://www.nationalgeographic. com/history/2020/03/how-cities-flattened-curve-1918-spanish-flupandemic-coronavirus/. Accessed April 10, 2020.
CEPI welcomes UK Government's funding and highlights need for $2 billion to develop a vaccine against COVID-19
CEPI welcomes UK Government's funding and highlights need for $2 billion to develop a vaccine against COVID-19. CEPI. https://cepi.net/ news_cepi/2-billion-required-to-develop-a-vaccine-against-the-covid-19-virus/. Accessed April 11, 2020. 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