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.
As of April 10, 2020, there are a total of 1,521,252 confirmed cases of
Coronavirus Disease 2019 (Covid-19), including 92,798 deaths reported to
WHO1. The pandemic has affected more than 190
countries around the world2. Described initially as a
pneumonia of unknown cause3 that was detected in Wuhan
City, Hubei Province of China, in December 2019, the SARS Covid-19 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 increasing the ability of the health services to cope with the
surge in cases4.
Some of us might have thought that cardiac surgeons will not be in the
Covid-19 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 Covid-19 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 Covid-19 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 surgeons5 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 equipment (PPE)
that was reported in many parts of the world, staff absences 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
conditions6, it is worrying that we do not fully
understand the immune 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
disease7.
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 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
plans8,9, 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 by-pass not amenable to percutaneous coronary
intervention or valve surgery not amendable to transcatheter aortic
valve replacement. While some scenarios can be straightforward, 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 Covid-19
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 cardiology.
However, how optimal are the long-term 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 Covid-19 positive 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
Covid-19 before transfer from peripheral hospitals. Covid-19 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 development
and retainment of telemedicine. One example is that most of our
follow-up clinics are now run by video or telephone call. Running 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 Covid-19 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
Covid-19 positive. Several studies are underway for the surgical
population in general10, 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
Covid-19 disease11.
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 virus4,6. After we flatten the curve, when and
how do we relax these restrictive measures in order to avoid a second
wave of infection is unknown. Certainly lifting such restrictions
prematurely could result in the so-called “double-humped curves” we
have seen in the H1N1 (Spanish flu) pandemic
191812,13. In 2020, we are in a better position, and
we can use sophisticated epidemiological modelling to inform policy
decisions4. There is no consensus on the best
therapeutic strategy for Covid-19 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 ongoing
research effort underway to evaluate various pharmacological agents
including antiviral medication, chloroquine, Chinese medicine products,
monoclonal antibodies and intravenous hyperimmune globulin from
recovered persons6. There is a hope for the
development of a vaccine that could be crucial in the suppression of the
outbreak. Two vaccines are in clinical evaluation and 60 more in
pre-clinical evaluation phase14. However, this race is
estimated to take at least 12-18 months15.
For now, we might have to live and work in the Covid-19 pandemic. By
working together and remaining resilient, we will return to our normal
lives and to our speciality – cardiac surgery where lots of work will
be expecting for us.