CARDIAC SURGE RY
Timing cardiac surgery in patients with COVID
Surgery in patients diagnosed with COVID-19 infection carries significant mortality and morbidity but the appropriate waiting period before surgical intervention after recovering from COVID-19 is not known. A team at St Bart’s Hospital, London, aimed to determine the safety of deferring surgery and the earliest safe period for surgery.
COVID-19 infection is associated with a high incidence of severe acute respiratory illness requiring invasive mechanical ventilation. Due to the rapid spread of the infection, the World Health Organization (WHO) declared COVID-19 a pandemic on 11 March 2020.1 Reports describe a high rate of mortality and morbidity (prolonged mechanical ventilation) in patients who underwent surgical procedures and were diagnosed with COVID-19 during the peri-operative period.2,3 In our own experience, developing COVID-19 in the immediate cardiac post-operative period carried a mortality up to 44%.4 It is difficult to predict the appropriate waiting period between COVID-19 diagnosis in an asymptomatic patient who requires urgent surgical intervention. Depending on the cardiac diagnosis, there might be an option to treat the patients medically, with less invasive procedures (i.e. PCI, TAVI or endovascular procedures) or to defer surgery until there is conversion of COVID-19 status to being negative. We aimed to identify the earliest safe period for surgery, by analysing our experience in patients who underwent cardiac surgery after recovering from COVID-19.
Methods Patients undergoing cardiac surgery in our centre from March to July 2020 were
analysed, with a focus on those diagnosed with COVID-19 during pre-operative work- up and who underwent cardiac surgery subsequently. COVID-19 diagnosis was defined as either a positive upper respiratory tract swab or by changes in the lung parenchyma on CT scan.
Our COVID-19 screening protocol consists of two consecutive nasopharyngeal swabs for polymerase chain reaction for ribonucleic acid (PCR-RNA) analysis, a non-contrast
In our experience, close monitoring in isolation allowed us to postpone surgery until COVID-19 negative result or substantial reduction in the viral load. With these measures we achieved good outcomes with no COVID-19-related complications in the post-operative period.
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CT chest to assess changes in the lung parenchyma suggestive of COVID-19 disease, lymphocyte count and Lactate Dehydrogenase (LDH) levels.5-8 The Cobas SARS-CoV-2 used for the PCR analysis targets two conserved genome regions (Orf and E genes) of the virus, and the test was positive if either target was detected. It also reports the cycle threshold (Ct value) or the number of cycles of amplification before the PCR product is detected as positive. Individual patient’s consent was waived by the Ethics Institutional Board since there was no patient identifiable data.
Results Ten patients were diagnosed with COVID-19 in the preoperative screening and subsequently underwent surgery: four patients by a positive nasopharyngeal swab, three by CT changes in the lung parenchyma and three by a combination. Male sex predominated (80%) and mean age was 65.8 (45-76
OCTOBER 2020
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