Coronavirus disease 2019 and cardiac surgery: lessons learnt from a round-trip to hell

Bonalumi and co-authors, on behalf of the COVID-SICCH Task Force of the Italian Society for Cardiac Surgery, addressed the very particular and difficult moment experienced by cardiac surgery during the first wave of the coronavirus disease 2019 (COVID-19) pandemic.1 The authors should be commended for their effort to analyze and summarize the various guidelines implemented worldwide with the aim to improve the reorganization of cardiac surgical departments. In their article, the authors comment on the different models proposed for the reallocation of resources and their effective application in clinical practice, outlining close interrelationships between cardiac operations performed in the midst of the pandemic and pandemic-related clinical events, most typically those related to the prothrombotic state determined by COVID-19. Italy was the first Western country hit by the initial outbreak of the COVID-19 pandemic, prompting the government to introduce restrictive measures and lockdown on 8 March 2020. The strain on an unprepared healthcare system determined near-saturation of intensive care beds in the northern regions, Lombardy in particular, and a consequent impossibility to guarantee regular hospital activity, with an obvious impact also on cardiac surgery. In this scenario, hospitals turned into hubs and spokes with an overall reduction of elective hospitalizations nationwide, with a synergy rather than a distinction between the two strategies to face the emergency, that is, hub-and-spoke vs. overall reduction. In most Italian regions, tertiary care centers remained hubs and highly specialized activity, including cardiac surgery, was temporarily stopped in minor centers, which were turned into spokes and COVID-19 hospitals. In Lombardy, conversely, hubs and spokes were determined on political grounds by the regional government with somewhat different criteria (DGR n. XI/2906 – Regione Lombardia). In brief, hospitals in Lombardy were rearranged according to four major fields for the referral of nondeferrable patients: major trauma and neurosurgery, stroke units, interventional cardiovascular procedures and cardiovascular surgery. For the latter, hubs needed to guarantee three concomitant operating rooms, 24-h acceptance and COVID-free pathways, including dedicated intensive care beds. Not all hospitals with these capabilities, however, were considered as hubs and cardiac operations were performed in only four centers in a region with a near-10 million population. Interestingly, three of four hubs were private hospitals with prior accreditation with the regional health system to provide a public service reimbursed by the regional government. Among them, one of the hubs is an academic hospital specialized in cardiovascular disease. On the other hand, in contrast to other Italian regions, the three public tertiary care centers performing heart transplantation in Lombardy were not authorized to continue regular surgical activity during the first outbreak of the pandemic. Worldwide, a global reduction in elective surgery was constantly observed, with peaks in urban areas.2–6 The strategies to tackle the pandemic were also a consequence of different healthcare systems. A reduction of hospital admissions regarding typical cardiovascular emergencies was observed, especially during the first outbreak of the COVID-19 pandemic.7 More specifically, admissions for acute coronary syndromes dropped significantly.8–11 In parallel, an increase in mechanical complications of myocardial infarction was observed at different institutions,12–14 indicating late presentation of evolved and untreated patients, a clinical scenario that goes back to the seventies. Similarly, the number of potential and actual organ donors in 2020 vs. 2019 decreased by 12.8 and 10.4%, respectively, on a national basis (data from the Sistema Informativo Trapianti, SIT) with a decrease in heart transplantation activity by 2.9% nationwide. In this scenario, Lombardy was the most affected region with a near-30% reduction in overall transplants, whereas donors increased in most of the other northern and some of the central Italian regions. Similar considerations apply to acute aortic syndromes, with fewer acute dissections observed during the outbreak, and to other fields of medical care, including delayed diagnosis of cancer.15 A key aspect addressed by Bonalumi et al. is the extreme difficulty, during the outbreak of the pandemic, in separating and clearly discerning fatal events directly because of COVID-19 from those related to other undiagnosed conditions, as many patients, especially in case of known cardiac disease, were advised to ‘remain home’ for fear of being infected. In turn, the general reluctance of patients towards hospitals, emergency departments in particular, magnified this phenomenon. The creation of separate pathways has been a mandatory and obvious step in the management and isolation of COVID-positive vs. negative patients. However, a grey zone regarding potentially infected patients and the development of a positive swab during hospitalization is inevitable. Bronchoalveolar lavage has been shown to provide a higher diagnostic accuracy for the detection of SARS-CoV2 and some institutions employed it routinely in surgical or other intubated patients after nonelective hospitalization with the impossibility to perform a nasopharyngeal screening swab during the preceeding 48–72 h.16 Another issue relates to the opportunity to operate on COVID-positive patients presenting with nondeferrable conditions. Evidence supports a higher operative risk in cardiac surgical candidates, likely not only because of an increased rate of respiratory complications in case of overt COVID-related pneumonia but also because of thrombotic complications.17 Interestingly, a potentially protective role of postoperative anticoagulation has been suggested in patients developing COVID-19 after cardiac operations.18 Finally, extracorporeal membrane oxygenation (ECMO) as an extreme resource was used to treat refractory respiratory failure in COVID-19. Although cardiac surgeons are not invariably involved, some areas are organized with centralized ECMO teams constituted of anesthesiologists and cardiac surgeons, and patients are transferred to a hub hospital. This setting not only applies to veno-arterial ECMO for cardiogenic shock but also to venovenous ECMO for acute respiratory distress syndrome (ARDS) and respiratory failure. During the pandemic, for instance, the ECMO team from Turin treated over 50 patients with COVID-related pneumonia throughout Piedmont. A similar number of ECMO implants in COVID patients was carried out by the team from Pavia. Results were dismal and nonhomogenous during the initial outbreak, with very poor overall survival, most likely secondary to late and compassionate indications for ECMO in unselected patients. More targeted indications for the allocation of this socially expensive resource determined a gradual improvement in outcomes with survival rates of over 50%.19 Noteworthily, mortality is near-double in comparison to ECMO support for ARDS secondary to H1N1 influenza.20 In conclusion, COVID-19 hampered healthcare systems worldwide at various levels, with up to 70–80% reduction of surgical activity during the initial lockdown period. Cardiac operations were no exception. Investment in health system resources has been lacking for too many years and is a crucial issue to face and, hopefully, prevent similar scenarios in the future. Every effort should now be focused to a ‘return-to-normal’,21,22 taking into account that the postponement of elective surgery not only affects the probability of cardiac-related death and adverse events while on the waiting list, but also determines longer intensive care length of stay and prolonged hospitalization related to the higher complexity of more urgent patients. Conflicts of interest There are no conflicts of interest.