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Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
https://doi.org/10.1186/s12872-021-02253-6
RESEARCH
The impact ofCOVID-19 pandemic onaortic
valve surgical service: asingle centre experience
Dimitrios Vlastos*, Ishaansinh Chauhan, Kwabena Mensah, Maria Cannoletta, Athanasios Asonitis,
Ahmed Elfadil, Mario Petrou, Anthony De Souza, Cesare Quarto, Sunil K. Bhudia, Ulrich Rosendahl,
John Pepper and George Asimakopoulos
Abstract
Background: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the
provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of
elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve
surgery activity at a single two-site centre in the United Kingdom.
Methods: Data were extracted from the local surgical database, including the demographics, clinical characteristics,
and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming opera-
tive activity and compared with the respective 2019 period. A similar comparison was conducted with the period
between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience
of centres world-wide was invoked to assess the efficiency of our services.
Results: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective
cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was signifi-
cantly higher [median Euroscore II was 2.7 [1.9–5.2] in 2020 versus 2.1 [0.9–3.7] in 2019 (p = 0.005)] but neither 30-day
survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient
ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommence-
ment of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era.
Conclusions: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first
COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of
elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial
to monitor.
Keywords: COVID-19, Aortic valve surgery, Service evaluation, Adult cardiac surgery, Pandemic
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Introduction
e severe acute respiratory syndrome coronavirus 2
and the attendant coronavirus-disease 2019 (COVID-
19) emerged in December 2019, resulting in a pandemic
declaration by the World Health Organisation by March
2020 [1]. By the end of May 2020 more than 6 million
cases and 374,000 fatalities had been reported world-
wide; for the United Kingdom, the reported incidence
was 90,000 and almost 10,000 respectively [2]. is has
imposed an unprecedented burden on the provision of
healthcare services in general, and surgical treatment
specifically [3]. e postponement of elective cases and
the redistribution of workforce and resources reshaped
the dynamics of surgical activity [3, 4].
Open Access
*Correspondence: dimitrisbvr@hotmail.com; d.vlastos@rbht.nhs.uk
Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Page 2 of 7
Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
Our aortic surgery team, among other cardiac surgical
teams, had the task to achieve a delicate balance between
patients whose treatment could be safely postponed,
versus patients with life-threatening advanced chronic
or emergency disease, in the context of severely limited
intensive care resources availability [5, 6]. On the one
hand, Pan-London Emergency Cardiac Surgery (PLECS)
protocol facilitated this by providing a centralised path-
way to COVID-19 protected surgical facilities [7]. On
the other hand, the correlation of cardiovascular risk fac-
tors with worse COVID-19 outcomes [8–10] as well as
the occasionally unpredictable trajectory of aortic valve
disease [11] further complicated this process. Moreover,
surgical theatre availability in our institution was severely
compromised during the first three months of our pan-
demic response, since one of the two sites served as an
exclusive COVID-19 Extracorporeal Membrane Oxy-
genation (ECMO) referral centre. Operative activity was
restored at both sites thereafter, significantly enhancing
our surgical volume capability.
Aims andobjectives
e aim of this service evaluation report is to provide an
objective assessment of the effects of COVID-19 pan-
demic on the cumulative aortic valve surgical activity at
our institution. More specifically, the number of opera-
tions undertaken between March and May 2020 -via the
modified cardiac surgery pathway- were compared with
the respective activity during the period from March
2019 to May 2019. A similar comparison was performed
with our activity between June 2020 and August 2020,
when our surgical volume capability was enhanced by
re-commencement of operations at both sites included
in our institution. In addition, a more detailed analy-
sis regarding the differential impact on elective versus
urgent or emergency cases, as well as on patients with
mild clinical disease versus severely symptomatic ones
was conducted. We also investigated how surgical mor-
tality and major post-operative complication rates were
affected, especially given the self-explaining prioritiza-
tion of severe and urgent/emergency cases. Lastly, we
assessed the effectiveness of our COVID-19 screening
protocol as denoted by the comparison of the pre- and
post-operative COVID-19 status of our patients.
Methods
Study design andpopulation
is was a retrospective study (service evaluation pro-
ject) conducted at the Royal Brompton and Harefield
NHS Foundation trust. It included a total of 384 adult
patients (mean age = 66.5 ± 13.5 years, 68.2% male)
undergoing aortic valve surgery, either isolated or with
concomitant procedures, for a primary aortic valvular
disease indication during the three studied periods
(namely March–May 2019, March–May 2020, and June–
August 2020). Patients undergoing aortic valve replace-
ment (AVR) for incidental valvular disease diagnosed at
pre-operative workup were excluded.
Statistical analysis
Data were extracted from the local surgical database and
analysed using the SPSS v20 software. ey included
the demographics and clinical characteristics of patients
treated over the periods of interest, type of operations
and their indication, pre- and post-operative COVID-
19 status, as well as major post-operative complica-
tions, namely re-sternotomy for bleeding or tamponade,
transient ischemic attack (TIA) or stroke, new need for
renal replacement therapy (RRT), and 30-day mortality.
Data with a non-gaussian distribution were expressed
as median (interquartile range) and were analysed after
transformation into ranks. Chi-square Fisher exact test
was used to compare categorical clinical characteristics
and outcomes during the two investigated periods. Inde-
pendent sample t-test was utilised for parametric ordinal
data. In all analyses, we used two tailed tests with p < 0.05.
Results
During March–May 2020 a total of 97 aortic valve sur-
gical procedures were undertaken, versus 157 during
the respective 2019 period (Table 1, Fig.1). 59% of the
patients were operated on an urgent or emergency setting
in 2020, versus 14% in 2019 (p < 0.001; Table 1, Fig.1).
ere was a 70% decrease in elective cases in 2020, in
contrast with a 159% increase in urgent/emergency cases
(p < 0.001; Fig. 1). Similarly, 11.3% of the operations were
for aortic valve endocarditis in 2020, versus 4.5% in 2019
(p = 0.038). e proportion of re-do operations did not
significantly differ (8.2% in 2020 versus 3.8% in 2019,
p = 0.135) and neither did the percentage of cases clas-
sified as New York Heart Association (NYHA) class III/
IV and/or Canadian Cardiovascular Society (CCS) class
III/IV (76.3% in 2020 compared with 64.3% in 2019,
p = 0.112). Median Euroscore II was 2.7 [1.9–5.2] in 2020
versus 2.1 [0.9–3.7] in 2019 (p = 0.005).
During the initial pandemic response there was a
38.2% reduction in the total number of operations
with a 70% reduction in elective cases, compared with
a 159% increase in urgent and emergency operations.
Recommencement of activity at both institutional sites
conferred a surgical volume within 17% of the pre-
COVID-19 era.
Importantly, despite the higher surgical risk of cases
in 2020, the frequency of the investigated major post-
operative complications was not adversely affected.
More specifically, no fatalities within 30 days were
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Page 3 of 7
Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
reported, compared with one fatality in the respective
2019 period (p = 0.58). Similarly, the incidence of re-
sternotomy for bleeding or tamponade was 3.1% versus
6.4% (p = 0.269), while the incidence of post-operative
neurologic impairment in the form of TIA or stroke
was 2.1% versus 1.9% (p = 0.54), for the 2020 compared
to the 2019 period, respectively. e incidence of renal
dysfunction necessitating RRT was 9.3% during the
outbreak, versus 5.1% (p = 0.186) during the respective
2019 period. All of our patients had a negative pre- and
post-operative COVID-19 status.
During June–August 2020, following resumption of
surgical activity at both sites, a total of 130 aortic valve
procedures were performed, compared with 97 during
the first wave period (Table2, Fig.1). 43% of the patients
were operated on an urgent or emergency setting during
June–August, versus 59% during the first wave (p = 0.026;
Table 2, Fig.1). In more detail, the absolute number of
urgent or emergency cases did not change, in contrast
with an 82% increase in the elective cases (p < 0.001).
In addition, there was a significant increase in the rela-
tive frequency of redo-operations to 18.4% (p = 0.04;
Table2). No significant difference was detected in either
the median Euroscore II risk classification, or any of the
investigated post-operative complications (Table2). Sim-
ilar to the first pandemic period, the pre- and post-oper-
ative COVID-19 status of all of our patients was negative.
Discussion
In this service evaluation project, we have demonstrated
that the COVID-19 pandemic resulted in a significant
decrease in the total number of conducted aortic valvular
operations in our trust. is decrease was mitigated by
the expansion of surgical activity over both of our trust
hospital sites. e prioritization of severe aortic valve
disease cases leaded to a relative increase of urgent and
emergent operations with an attendant enhanced opera-
tive risk. Importantly, neither mortality nor major post-
operative complications rate increased. Furthermore, our
stringent pre-operative COVID-19 screening protocol
prevented contraction of COVID-19 among our surgical
cohort.
e intensity of COVID-19 had a major impact on
the provision of surgical services worldwide [3–6]. e
perioperative dependence of cardiac surgery patients
on Intensive Care Unit (ICU) care, on which a signifi-
cant component of the pandemic response was placed,
and the concomitant reallocation of staff and equipment
particularly complicated their management [6, 12, 13].
In this context, Pan-London Emergency Cardiac Sur-
gery (PLECS) service was formed to provide a central-
ised pathway for urgent and emergency cases in London
[7]. Royal Brompton and Harefield trust was one of the
two centres selected, based on its surgical capacity, loca-
tion, and absence of Accident & Emergency department.
ese characteristics provided the capability of accom-
modating high surgical volumes in a COVID-19 free
environment.
Our modus operandi resembled the guidelines per-
taining to cardiac surgery services during the pandemic
response, issued by the Lombardi Region [14]. In specific,
a hub-and-spoke system was implemented: Harefield
Hospital site played the hub role during the first pan-
demic period (March–May 2020) allowing continuation
Table 1 Number and type of operations, risk assessment, and
major post-operative complications during the initial pandemic
response compared to the pre-COVID-19 era
Period March–May
2019 (n = 157) March–May
2020 (n = 97) p-value
Age, mean (SD) 65.5 (13.4) 66.5 (13.5) 0.45
Male 105 (66.8%) 66 (68%) 0.34
Ethnicity
White 117 (75%) 74 (76%) 0.3
Asian 5 (3%) 2 (2%) 0.2
Black 5 (3%) 2 (2%) 0.46
Other 30 (12%) 19 (20%) 0.23
Ischaemic heart disease 34 (21.7%) 18 (18.6%) 0.274
Chronic lung disease 23 (14.6%) 17 (17.5%) 0.48
Hypertension 96 (61.1%) 62 (63.9%) 0.52
Diabetes 29 (18.5%) 19 (19.6%) 0.28
Dyslipidaemia 57 (36.3%) 30 (30.9%) 0.56
Chronic kidney disease 14 (8.9%) 12 (12.3%) 0.25
Coagulopathy 7 (4.5%) 3 (3.1%) 0.6
Chronic liver disease 3 (1.9%) 2 (2.1%) 0.34
Malignancy 2 (1.3%) 1 (1%) 0.65
Type of operations
AVR 77 52 N/A
AVR + CABG 32 15 N/A
AVR + aortic 29 17 N/A
AVR + MVR 8 3 N/A
Multivalvular/complex 11 10 N/A
Euroscore II (median [IQR]) 2.1 [0.9–3.7] 2.7 [1.9–5.2] 0.005
Urgent/emergency setting 22 (14%) 57 (59%) < 0.001
NYHA/CCS III/IV 101 (64.3%) 74 (76.3%) 0.112
Endocarditis 7 (4.5%) 11 (11.3%) 0.038
Re-do operations 6 (3.8%) 8 (8.2%) 0.135
30-day mortality 1 (0.6%) 0 (0%) 0.58
Re-sternotomy for bleeding 10 (6.4%) 3 (3.1%) 0.269
TIA/stroke 3 (1.9%) 2 (2.1%) 0.54
New need for RRT 8 (5.1%) 9 (9.3%) 0.186
Pre-operative COVID-19 N/A 0 (0%) N/A
Post-operative COVID-19 N/A 0 (0%) N/A
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Page 4 of 7
Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
of operations via a common referral pathway, while Royal
Brompton served as a spoke component, temporar-
ily withholding surgical activity in order to accommo-
date the increasing ECMO referrals. e expansion of
critical care bed availability and the COVID-19 status-
based compartmentalisation allowed the continuation
of operations at both trust sites during the second pan-
demic period (June–August 2020), while minimising the
COVID-19 contraction risk.
To this end, a stringent admission protocol was uti-
lised. All patients were screened with 2 serial COVID-19
swabs, one taken within 72 h of admission and a sec-
ond taken on admission (within 48h of their predicted
operative date). Patients at home would need to shield
completely for 14days and would have a pre-admission
workup including a COVID-19 swab obtained 3 days
prior to admission. ey were subsequently admit-
ted 2days prior to their surgery with a COVID-19 risk
determined as ‘GREEN’ (COVID-19-negative). Patients
transferred from other hospitals would only be trans-
ferred to our institution with a negative COVID-19
swab obtained within 72h of transfer. As these patients
had not been shielding, they were treated as potentially
COVID-19 positive (‘AMBER’) and were barrier nursed
in-side rooms until their status could be determined.
All patients had a CT scan performed in the immediate
pre-operative period (1–2 days before the provisional
operation date). A positive swab or any suspicious radio-
logical findings would place the patient in the ‘RED’ risk
group (COVID-19-positive) and would be an indication
to defer the operation; in the interim the patient would
be under the care of Respiratory Medicine until 2 nega-
tive COVID-19 swabs were provided. As a result, none of
our patients contracted the disease over the investigated
period, underlining the effectiveness of this protocol.
is has important clinical implications as signified by a
recent study including nine United Kingdom (UK)-based
cardiac surgery centres, where COVID-19 diagnosis was
independently associated with a 21% increase of in-hos-
pital mortality and a prolongation of median length of
stay by 6days [15].
e COVID-19 pandemic resulted in a significant
reduction of cardiac surgery operations worldwide.
According to a recent survey that included 60 cardiac
surgical centres globally, there was a median reduction of
50–75%, while most of the contributing hospitals aban-
doned the provision of elective care. In 5% of the centres,
all surgical activity including emergency operations was
withheld. Importantly, these detrimental effects were
similarly evident in high- and low-volume centres [12].
Similarly, national-wide in the UK an 83% reduction in
index cardiac cases over the March–May 2020 period
was documented [6]. An interesting study that extracted
national-wide data from the Hospital Episode Statistics
Fig. 1 Surgical aortic valve procedures according to time period
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Page 5 of 7
Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
National Health Service (NHS) database demonstrated
that surgical AVR was among the most intensely affected
procedures, with a 91% decrease in cases performed dur-
ing March–May 2020 compared with the mean number
of operations conducted over the respective 2018 and
2019 period [16]. In the United States (US), the pandemic
caused a reduction in cardiac surgery cases by 53%: elec-
tive cases were reduced by 65%, but non-elective opera-
tions were also significantly affected with a decrease of
40%. ese effects were enhanced in Mid-Atlantic region,
where a decline of 71% was documented [17]. Even in
countries where COVID-19 was initially contained due to
strict restrictive measures, valvular heart disease opera-
tions were among the most severely affected procedures:
75% reduction in surgical caseload was reported by two
large Greece-based centres [18]. On the other hand, an
aortovascular disease centre in the UK managed to main-
tain its surgical volume during the investigated outbreak
period [13]. Moreover, a self-explanatory increase in
the proportion of emergency and urgent cases has been
demonstrated. While most of the studied centres aban-
doned the provision of elective surgical care [12], a large
UK-based aortovascular centre equally distributed its
operations between elective and emergency care [13].
Other hospitals experienced doubling of their emergency
cases relative caseload to 32.1% [18]. Our trust appears
to have performed non-inferiorly, demonstrating a 38%
initial reduction of AVR caseload, which was mitigated
by the resumption of activity across both trust sites to
17%. Urgent and emergent cases constituted the great-
est component of our workload over the first pandemic
period, with an even distribution over the June–August
2020 period.
A national-wide UK registry report revealed that mor-
tality of surgical AVR performed during the first pan-
demic period was not compromised, despite the relative
increase of urgent/emergent cases and the attendant
increased risk [16]. However, COVID-19 per se exerted
detrimental effects by way of a 21% increase in mortal-
ity and a significant prolongation of length of stay [15].
A US-based study that obtained data from the Society
of oracic Surgery (STS) Adult Cardiac Surgery Data-
base demonstrated a detrimental effect of the pandemic
on surgical mortality. In specific, the observed-to-
expected (O/E) mortality ratio in the Mid-Atlantic and
New England regions rose to 1.2 for isolated coronary
artery bypass graft (CABG) cases, corresponding to an
increase of 167%; the respective increase for all cardiac
surgery procedures was 110% [17]. ese observations
were attributed to patients presenting at more advanced
disease states leading to an augmented non-elective
operations relative frequency with an attendant increase
in surgical risk. Our unit managed to preserve the pre-
COVID-19 surge mortality and major post-operative
complications rate despite the significantly increased
risk; the efficiency of our COVID-19 screening protocol
appears to have contributed significantly in the light of
the above-mentioned study findings [15].
Despite the apparent non-inferiority in the quantity
and quality of our cardiac surgical services during the
pandemic response, the 70% initial reduction in elective
activity suggests the development of a significant backlog
of cases; this was mitigated by the resumption of opera-
tive activity at both institutional sites, which conferred
a significant increase of elective activity by 82%. e
Table 2 Number and type of operations, risk assessment, and
major post-operative complications progression following
recommencement of surgery at both trust sites
Period March–May
2020 (n = 97) June–August
2020 (n = 130) p-value
Age, mean (SD) 66.5 (13.5) 67.4 (13.7) 0.683
Male 66 (68%) 89 (68.4%) 0.74
Ethnicity
White 74 (76%) 94 (72%) 0.654
Asian 2 (2%) 4 (3%) 0.43
Black 2 (2%) 4 (3%) 0.231
Other 19 (20%) 28 (22%) 0.343
Ischaemic heart disease 17 (17.5%) 20 (15.4%) 0.245
Chronic lung disease 17 (17.5%) 21 (16.2%) 0.62
Hypertension 62 (63.9%) 83 (63.8%) 0.544
Diabetes 19 (19.6%) 23 (17.7%) 0.4
Dyslipidaemia 30 (30.9%) 42 (32.3%) 0.254
Chronic kidney disease 12 (12.3%) 10 (7.6%) 0.37
Coagulopathy 3 (3.1%) 5 (3.8%) 0.5
Chronic liver disease 2 (2.1%) 3 (2.3%) 0.661
Malignancy 1 (1%) 2 (1.5%) 0.225
Type of operations
AVR 52 61 N/A
AVR + CABG 15 18 N/A
AVR + aortic 17 29 N/A
AVR + MVR 3 8 N/A
Multivalvular/complex 10 14 N/A
Euroscore II (median [IQR]) 2.7 [1.9–5.2] 2.8 [1.5–5.2] 0.469
Urgent/emergency setting 57 (59%) 57 (43%) 0.026
NYHA/CCS III/IV 74 (76.3%) 101 (77.7%) 0.417
Endocarditis 11 (11.3%) 16 (12.3%) 0.55
Re-do operations 8 (8.2%) 24 (18.4%) 0.04
30-day mortality 0 (0%) 3 (2.3%) 0.2
Re-sternotomy for bleeding 3 (3.1%) 10 (7.7%) 0.167
TIA/stroke 2 (2.1%) 4 (3%) 0.38
New need for RRT 9 (9.3%) 7 (5.4%) 0.178
Pre-operative COVID-19 0 (0%) 0 (0%) 0.628
Post-operative COVID-19 0 (0%) 0 (0%) 0.628
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Page 6 of 7
Vlastosetal. BMC Cardiovasc Disord (2021) 21:434
backlog may mainly include patients with asymptomatic
or mildly symptomatic disease; however, given the non-
negligible occurrence of sudden cardiac death even in
asymptomatic patients with advanced aorticvalvular dis-
ease (especially aortic stenosis [11]), following normali-
sation of operative activity across both sites, these cases
should optimally be accommodated to minimise the pos-
sibility of any preventable deaths. is is further high-
lighted by evidence form healthcare systems of routine
limited capacity, where longer cardiac surgical waitlists
have been associated with worse operative mortality [19].
Conclusions
Our aortic valve surgical services were significantly
affected by the COVID-19 pandemic, resulting in prior-
itization of urgent and emergency cases and deferral of
elective treatment. Despite the increased attendant sur-
gical risk, perioperative mortality and major morbidity
were not increased. It would be of interest to follow-up
patients treated during the pandemic and investigate for
longer-term consequences as well as to evaluate how the
backlog of elective cases will be accommodated after nor-
malisation of surgical activity.
Abbreviations
AVR: Aortic valve replacement; CABG: Coronary artery bypass surgery;
CCS: Canadian Cardiovascular Society angina pectoris grading; COVID-19:
Coronavirus-disease 2019; ECMO: Extracorporeal Membrane Oxygenation; ICU:
Intensive care unit; MVR: Mitral valve replacement/repair; NHS: National Health
Service; NYHA: New York Heart Association functional classification; PLECS:
Pan-London Emergency Cardiac Surgery; RRT : Renal replacement therapy; TIA:
Transient ischaemic attack; UK: United Kingdom; US: United States.
Acknowledgements
Not applicable.
Authors’ contributions
DV: concept/design, data analysis/interpretation, drafting, critical revision.
IC: concept/design, data collection. KM: critical revision, drafting. MC: critical
revision. AA: data collection. AE: data collection. MP: critical revision. ADS:
critical revision. CQ: critical revision. SKB: critical revision. UR: critical revision. JP:
concept/design, critical revision. GA: concept/design, data interpretation, criti-
cal revision, approval. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
The data that support the findings of this study are available on reasonable
request from the corresponding author. The data are not publicly available
due to privacy or ethical restrictions.
Declarations
Ethics approval and consent to participate
Our clinical audit (service evaluation study) was approved by the Royal
Brompton Hospital audit department: audit project approval ID # 003929;
programme # 002490 RBH Adult Hert. According to the National Clinical Audit
and Patient Outcomes Programme commissioned by the Healthcare Quality
Improvement Partnership on behalf of the National Health Service no need
for consent was by definition deemed necessary, while the pertinent ethical
framework was strictly adhered to, including the Caldicott Principle (1997),
the Data Protection Act (1998), and the NHS Confidentiality Code of Practice
(2003).
Consent for publication
Not applicable.
Competing interests
We declare no support from any organisation for the submitted work; no
financial relationships with any organisations that might have an interest in
the submitted work; no other relationships or activities that could appear to
have influenced the submitted work.
Received: 17 March 2021 Accepted: 7 September 2021
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