CARDIAC SURGE RY
the infiltrates. None of the patients developed pyrexia (> 38˚C) while waiting for the operation and only one patient developed progressive breathlessness, probably due to acute heart failure.
Mean Euroscore was 3.3 (1.09 – 7.93). Surgical procedures were: CABG (n= 4), CABG + mitral replacement (n= 1), mitral repair (n= 1), AVR (n= 2), aortic replacement (n= 2); mean bypass and cross clamp time was 122.4 (67-305) and 82.8 (36-158) minutes respectively. All surgeries were conducted with PPE precautions taken during the operation and post-operative period. None of the patients developed COVID- 19-related respiratory complications in the post-operative period and were extubated uneventfully in the first two days. Mean mechanical ventilation times were 7.5 hours (4-24 hours), mean ITU stay was 2.9 days (1-4 days), and total length of post-operative stay 11.9 days (4-48 days). Post-operative swabs after surgery (taken between post- operative days 1-9) were negative for all patients. All patients survived to hospital discharge. (Table 2).
Discussion
Developing COVID-19 during the immediate post-operative period, regardless of the nature of the surgical procedure, carries a high mortality and morbidity related to respiratory complications.2-4
In emergencies
there is no option to wait for the swab results as the surgical indication outweighs the risk of COVID-19. However, in urgent cases, with at least 24-48 hours margin to wait for the screening results, we encountered a proportion of patients who were COVID-19 positive with mild or no symptoms.5 The ideal convalescence period after having tested positive for COVID-19 is unknown, especially in the absence of symptoms or abnormalities in the chest imaging. We believe it is important to manage each case individually and, when time permitting, to wait until negative for COVID-19 testing or drastically reduced viral load and resolution of the radiological infiltrates (if any).
The accuracy of the COVID-19 diagnostic tests is still suboptimal, with a high percentage of false negatives.9
Furthermore,
a positive test does not necessarily indicate infectious virus particles in a patient with resolving infection. The Ct value can be seen as a relative concentration of the target in the PCR reaction or a pseudo-measure of the viral load (the lower the Ct value, the higher the concentration of viral particles). Correlation between isolation of SARS-CoV-2 in cell culture and Ct value suggests that patients with COVID-19 with Ct above 24 or 26 could be considered non-contagious.10 In our series, all patients who required urgent surgery had Ct values above that threshold and, hence, were probably not
References 1 World Health Organization. WHO announces COVID-19 outbreak a pandemic. World Heal. Organ. 2020;3.
http://www.euro.who.int/en/ health-topics/health-emergencies/coronavirus- covid-19/news/news/2020/3/who-announces- covid-19-outbreak-a-pandemic.
2 Cai Y, Hao Z, Gao Y, Ping W et al. Coronavirus disease 2019 in the perioperative period of lung resection: a brief report from a single thoracic surgery department in Wuhan, People’s Republic of China. J Thorac Oncol. 2020 Apr 11:S1556- 0864(20)30298-7.
3 Lei S, Jiang F, Su W, Chen C et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. E Clinical Medicine. 2020 Apr 5:100331.
Figure 1. Intraoperative picture during aortic valve replacement.
4 Yates M, Balmforth D, Lopez-Marco A, Uppal R et al. Outcomes of patients diagnosed with COVID-19 in the early post-operative period following cardiac surgery. Interact CardioVasc Thorac J Published online first 2020.
5 SCTS. St Bartholomew’s Hospital Theatre Standard Operating Protocol for COVID-19. 2020.
https://scts.org/wp-content/uploads/2020/04/ St-Bartholomews-Theatre-SOP-for-COVID-19-8th- April-2020.pdf (accessed 23 Apr 2020).
6 Hope MD, Raptis CA, Shah A, et al. A role for CT in COVID-19? What data really tell us so far. Lancet 2020 395;1189-90.
7 Han Y, Zhang H, Mu S, et al. Lactate dehydrogenase, a Risk Factor of Severe COVID-19 Patients. medRxiv 2020 doi:10.1101/2020.03.24.20040162.
Figure 2. Coronary artery revascularisation surgery.
infectious. By delaying the operation, we also allowed the resolution of the associated systemic inflammatory reaction and thus did not see any complication in the immediate post-operative period. The median Ct values for the non-urgent patients who had their surgeries deferred was lower than that of those who required urgent intervention. 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. However, it might not be necessary to wait until total resolution of radiological changes or a negative PCR result, but further studies on a larger volume of patients are needed to confirm this.
Conclusions Postponing cardiac surgery in selected patients with confirmed COVID-19 was safe and enabled surgery to be performed with favourable outcomes in patients with low viral load and or radiological resolution of the lung infiltrates.
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8 Tan L, Wang Q, Zhang D, et al. Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study. Signal Transduct Target Ther 2020 27:5:33.
9 Li Y, Yao L, Li J, et al. Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19. J Med Virol 2020 92:903-8.
10 La Scola B, Le Bideau M, Andreani J, Hoang VT et al. Viral RNA load as determined by cell culture as a management tool for discharge of SARS-CoV-2 patients from infectious disease wards. Eur J clin Microbiol Infect Dis 2020. 39:1059-1061.
Authors
Ana Lopez-Marco1 Cristina Suarez2 Balmforth1 Das2
, Aung Oo1
, Martin Yates1 , Azhar Hussain1
, , Damian
, Robert Serafino Wani2, Satya .
Institutions and affiliations: Departments of Cardiothoracic Surgery1 Microbiology2
and , St Bartholomew’s Hospital, London.
Corresponding author: Ana Lopez-Marco, St Bartholomew’s Hospital, London. E-mail:
ana.lopez-marco@nhs.net
CSJ OCTOBER 2020
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