Discussion
The developed world is currently facing what seems to be a watershed,
and no doubt one of the significant landmarks in the history of
medicine. One of the greatest challenges of the medical community is the
scarcity of knowledge and experience in facing this virus. (2-3)
Apart from the common typical viral symptoms (i.e. fever, cough,
fatigue, dyspnea, and diarrhea) or, in more severe cases, pneumonia and
ARDS, COVID-19 also has some significant consequences on the
cardiovascular system and the management of cardiovascular patients. The
first association between COVID-19 and the cardiovascular system is the
increased risk in patients with pre-existing cardiovascular disease to
develop severe disease and death. Second, complications such as
myocarditis (8-10) acute myocardial infarction (11), arrhythmias (9),
thromboembolic events (12-14), and heart failure (11,14), have been
linked to COVID-19 infection. In some cases, these complications
engendered treatment with ECMO (15-17). Third, reports on cardiovascular
side effects of COVID-19 therapies have been published (18-20), and
lastly, the pandemic’s consequences regarding non-COVID-19
cardiovascular patients. New policies have affected virtually each and
every medical discipline, specifically those of surgeons in various
fields who were required to apply a triage never before seen in their
daily routine practice (3,6,7). Meanwhile, increasing numbers of
patients are avoiding medical care while being symptomatic at home. As
the pandemic is still ongoing, the aftermath remains largely unclear,
with emerging reports of patients deteriorating or dying at home.
However, it will be difficult to quantify the impact of non-COVID-19
morbidity and mortality during the COVID-19 pandemic. While the number
of infected patients is objectively quantifiable, the number of
non-COVID-19 patients suffering from the outbreak’s consequences is far
from being measurable. In other words, the impact of the virus is not
solely from personally transmitted infection.
One of the aspects of this may be illustrated in the field of cardiac
surgery. At the beginning of the outbreak, Légaré et al., on
behalf of the Canadian Society of Cardiac Surgeons (CSCS), released a
guidance statement to cardiac surgeons. They suggested a template for
triaging patients based on the percentage in reduction of services.
According to their suggestion, upon a mild reduction in services
(0-30%), only symptomatic outpatients or those at greater risk for
developing adverse events, should undergo surgery alongside the urgent
cases. Under a >50% reduction in services, they suggested
operating on urgent cases only (4,7).
Israel was one of the first responders to the crisis, and consequently
there has been a significant reduction in the number of cardiac
surgeries performed. Evidently, characterizing the preoperative status
of the entire patient cohort, those of the COVID-19 era were not
necessarily sicker, but rather more symptomatic. Coincidentally or not,
this correlates with the CSCS recommendation, although no guidance
statement has been released by the Israel Society of Cardiothoracic
Surgery. Apart from the obvious reasons, another consideration
advocating for the delay of asymptomatic elective cases is the
incubation period of COVID-19. A recent paper reported on patients who
tested negative for COVID-19 during their asymptomatic incubation period
and then underwent various surgical procedures. The mortality rate of
these patients was dramatically high (20.5%) (21). Conversely, it could
be argued that symptoms are subjective rather than objective parameters,
and there might be some clinical discrepancies between NYHA and the
severity of the disease.
One of the most intriguing facts demonstrated by this study emerged from
the operative data. While there was no net difference in terms of types
and complexity of procedures, patients from the COVID-19 era had longer
procedural time. It could be that the cases selected in 2020 were more
complex and challenging. However, it is difficult to ascertain whether
the underlying reason for this is a more complex anatomy, late hospital
arrival, or simply a coincidence.
Several factors may contribute to the higher rate of in-hospital
mortality for patients in the 2020 group (13% vs. 5.2%). The first is
the aforementioned assumption of more challenging procedures. The second
hypothesis is possibly related to late hospital arrival of patients
during the COVID-19 pandemic, which may have worsened their underlying
condition. With the pandemic progressing worldwide, panic grew within
the population, and indeed patients avoided hospitals even at the cost
of being symptomatic.
May 2020 was a positive turning point in Israel concerning COVID-19. The
“curve” seemed to be flattened and the number of new positive cases
declined daily, together with the governmental restrictions including
those concerning medical practices. This prompted the question of when
to restore the daily routine in the field of interventional cardiology
and cardiac surgery. In fact, the number of patients is growing on a
daily basis and elective cases are now performed routinely. The safety
of the medical teams remains the first priority, and the primary goal is
to proactively manage all surgical cases including comprehensive
COVID-19 screening protocol for both patients and personnel.
Now that the first major outbreak of COVID-19 seems to be fading away,
cardiac surgeons must bear in mind that a second outbreak might be
coming soon. Therefore, it is imperative that cardiac surgery teams
should be vigilant and learn from their own experience and the
experience of others. It is a call for surgeons to be aware of the
possible and probable impact of COVID-19 on non-COVID-19 patients.