Manuscript Text:
To date on 20 June 2020, more than 8,500,000 patients have been affected
by Covid19 and more than 450,000 have died worldwide (1). The epidemic
that initially started in Hubei Province in China at the end of December
2019 has rapidly spread worldwide to 200 countries (2). The pandemic is
improving according to the latest figures in the United States, the most
affected country, and for the rest of the world except Latin America.
Our policy as cardiac surgeons throughout this period of lock-down was
to delay all elective procedures on the one hand, and to refer patients
to less invasive percutaneous coronary intervention (PCI), transcatheter
aortic valve replacement (TAVR) or transcatheter mitral valve
replacement (TMVR) procedures on the other hand. Most cardiac surgeons
limited surgery to cases such as acute aortic dissections, emergency
coronary artery syndromes not amenable to PCI or time-sensitive valve
surgery not amenable to TAVR or TMVR (3). With the first signs of
resolution of the pandemic and the start of delivery in several European
countries, a significant number of patients are expected to be treated:
patients who are symptomatic but who preferred not to consult during the
lockdown period and asymptomatic ones who had delayed or cancelled
appointments for follow-up of their chronic diseases. Elderly,
overweight, hypertensive and diabetic male patients are currently known
to pay the highest price and mortality in these patients is higher than
in the rest of the population (4).
Given that elective cardiac surgery activity has fallen by at least 50%
according to Salenger et al, the post-Covid19 period should result in an
increase of 216% to 263% per month in the number of patients to be
treated (5). The period required to absorb the delay in patient
management will vary between 1 and 8 months depending on the date of
resumption of full activities and the capacity of hospitals to absorb
these volumes (5). There will be coronary patients who have had an
inadequately managed myocardial infarction, resulting in complications
such as heart failure, myocardial aneurysm, and mitral insufficiency due
to chordal or papillary muscle rupture and other mechanical
complications. There will be patients suffering from severe aortic valve
stenosis presenting syncope, severe dyspnea at rest or resting angina.
There will also be patients with severe mitral valve insufficiency
complicated by acute pulmonary edema.
These complicated patients have a longer intensive care unit (ICU) stay,
require more resources and have a higher morbidity and mortality.
In order to be able to absorb these potentially complicated patients who
were poorly followed during the pandemic, hospitals have to make the
necessary material and human resources available. Unfortunately, they
usually suffer from budget restrictions and are under the influence of
drastic cost-cutting programs, which explains the challenges to increase
their capacities. As things progress the intensive care unit beds
dedicated to Covid19 become available, elective cardiac surgery activity
will increase crescendo.
Residents as well as fellows who have been surgically on standby and who
have been actively involved in resuscitation care in Covid19 units
throughout the pandemic period should resume their training and
education programs.
Given that the coronavirus may not disappear in the immediate future,
and that the scenario of a second wave is plausible, cardiac surgical
practice must adapt to these circumstances with an emphasis on frequent
hand washing, barrier procedures, social and physical distancing. All
scheduled patients for elective surgery should be screened for Covid19
prior to surgery and all emergent surgical patients should be considered
Covid-positive until proven otherwise. This will break the chain of
contamination and preserve the medical and paramedical teams. Caregivers
affected by the Coronavirus have been quarantined for at least two weeks
and until symptoms improve. This absenteeism has inevitably reduced the
human capacities of the cardiac surgery and post-cardiac surgery
resuscitation departments. A growing number of learned societies have
begun to issue recommendations for the post-Covid19 period, such as the
Canadian Society of Cardiac Surgeons, which has projected a return to
normal surgical activity in three phases beginning with urgent patients
and those who are less likely to require prolonged ICU and hospital
length stay. The third phase is an increase of 100% of the capacity
with a return to normal outpatient services while continuing to
prioritize those at greatest risk on the wait list (6). During all
phases patients on the wait list for surgery should be contacted to
determine their symptoms to facilitate prioritization. Programs are
encouraged to adopt a mechanism by which patients who are having
increased symptoms or who are not doing well can contact the program to
receive additional screening while waiting. Finally, the Extracorporeal
Life Support Organization (ELSO) provides guidance regarding ventricular
assist device (VAD), cardiac transplantation and mechanical circulatory
support (including extracorporeal membrane oxygenation or ECMO)(6).