key: cord-297208-f4ob3ox6
authors: Pisano, Antonio; Landoni, Giovanni; Verniero, Luigi; Zangrillo, Alberto
title: Cardiothoracic surgery at the time of COVID-19 pandemic: lessons from the East (and from a previous epidemic) for western battlefields
date: 2020-05-06
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.04.051
sha: 
doc_id: 297208
cord_uid: f4ob3ox6

nan

health systems and forcing hospitals to draw resources from other clinical settings such as elective surgery. On the other hand, stopping non-urgent hospital admissions and postponing elective surgical interventions is also pivotal in order to limit contagion within hospitals.

However, there are healthcare activities which cannot be stopped, nor reduced by a great extent, and cardiothoracic surgery definitely is among them. Indeed, apart from diseases which require urgent/emergent surgical treatment (e.g. aortic dissection, thoracic trauma, endocarditis, intracardiac tumors, etc.), also many "elective" cardiothoracic procedures cannot be postponed for long, particularly valve replacement/repair in symptomatic patients, coronary artery bypass graft (CABG) surgery in patients with left main coronary artery disease, and lung malignancies surgery. Accordingly, hospitals should implement strategies to perform these procedures safely in patients with suspected or confirmed COVID-19, but also to prevent contagion among patients and healthcare personnel by newly admitted patients (as well as by healthcare workers themselves) with unapparent infection. 5 In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, a Special Article by Tan and coll. 6 describes the protocols and organizational changes for the management of cardiothoracic surgery in suspected or confirmed COVID-19 patients at the largest adult cardiothoracic tertiary center in Singapore. The authors report a series of scrupulous measures aimed at preventing contagion among patients and healthcare workers and at avoiding contamination of environments and medical instrumentation. Key points outlined in the article include: the need for careful planning and training, also through simulation, before performing cardiothoracic surgery in suspected or confirmed COVID-19 patients; the challenge of minimizing the risk of admitting undiagnosed SARS-CoV-2 infected patients to the cardiothoracic center; the availability of negative-pressure inpatient rooms in all hospitals and the need for negative-pressure operating theatres (as well as the expedient to keep the operating room doors closed for at least 10 minutes after tracheal intubation or extubation in order to allow high efficiency particulate air filters to remove 99% of the particulate air matter, in the absence of negative-pressure operating rooms); the use of adequate personal protective equipment (PPE); the creation of physically separate routes (including dedicated entrances and lifts) for suspected or confirmed COVID-19 patients; the systematic surveillance and screening of healthcare staff and visitors (the latter reduced to a minimum); and the division of staff members into separate teams in order to prevent crosscontamination among healthcare personnel if one surgical team should be accidentally exposed to a patient with unapparent SARS-CoV-2 infection.

Remarkably, these measures and organizational changes were adopted long before Singapore became the country with the highest number of COVID-19 confirmed cases outside of China, while some of them are still difficult (if not impossible) to implement in many western countries which have now far exceeded the number of Singapore cases and casualties. 1 Evidently, countries which faced the severe acute respiratory syndrome (SARS) outbreak, the first coronavirus pandemic of the current century which affected more than 8000 people (mainly in China, Vietnam, Singapore and Canada) in 2003 7 , were much more prepared, both culturally and in terms of facilities and equipment, as compared with western countries (many of which had to face, in the initial stages of the emergency, the shortage of even simple and cheap devices such as surgical masks). 8 However, maybe also thanks to the particular geographic and economic features of Singapore, the response to the current health emergency implemented at the Singapore National Heart Centre appears to be particularly punctual and comprehensive even as compared with the protocols (though detailed and certainly adequate according to the local conditions) adopted in hospitals of other countries which were highly affected by the 2003 SARS epidemic 9,10 , and should be probably regarded as a reference model. Until recently, Italy was the country with the highest number of confirmed COVID-19 cases worldwide. 1 As of April 15, 2020, the total number of people with documented SARS-CoV-2 infection in Italy was 165,155, with more than 21,000 casualties 11 , as compared with 3252 cases (and 10 deaths) in Singapore. 1 The two hospitals in which we work are in the frontline in the management of COVID-19 patients and, at the same time, are important reference centers for cardiothoracic surgery in the North and South of Italy, respectively. In particular, San Raffaele Hospital is the referral hub for cardiovascular urgencies/emergencies in Lombardy, the Italian region most affected by the epidemic. As shown in Table 1 , despite the reduction or suspension of ordinary hospitalizations and elective surgical activity, the number of cardiac surgical procedures at our centers remained rather significant.

Given the wide spread of contagion (which is likely largely underestimated due to the hypothesized high number of asymptomatic or mildly symptomatic infections 5,12 ), the major concern of clinicians who are not directly involved in the care of COVID-19 patients, but work in high-specialty settings such as cardiac surgery, is the inadvertent admission of patients with undiagnosed SARS-CoV-2 infection, with the consequent risk of spreading contagion among healthcare workers but especially among patients whose comorbidities and clinical conditions possibly predispose them to worse outcomes following SARS-CoV-2 infection. 5 Indeed, the same features of the COVID-19 disease which most likely have contributed to the very high number of contagions worldwide make the containment of this risk very challenging. These include: the relatively long incubation time (mean 5.2 days, but up to approximately 14 days or more) 13 ; the possible person-to-person transmission from asymptomatic individuals or even in either the prodromal or convalescence phase of the disease 5 ; the suggested significant percentage of false negative results with nasal swab testing (approximately one in three) 14 ; and the high estimated number of asymptomatic infections itself.

Most hospitals (including those where we work) are adopting important measures to limit contagion among patients and healthcare workers, such as reducing non-urgent admissions and surgical activity, limiting visitors, trainees, and students access, performing staff surveillance (through either temperature recording or laboratory screening), requiring nasal swab for research of SARS-CoV-2 before patients are transferred from other hospitals or performing it upon admission, and using surgical masks all the time and anywhere in the hospital. In addition to these measures, Tan and coll. 6 report other important measures which, in our opinion, should be shared at a nationwide (or at least regional) level, particularly the division of staff members into separate surgical teams (to avoid, as mentioned, cross-contamination among healthcare workers in case of accidental exposure to undiagnosed COVID-19 patients), the clear distinction of personnel caring for COVID-19 patients from that caring for other patients (including with regard to highly skilled teams such as those of extracorporeal membrane oxygenation services), and the need for infectious disease specialist consultation and agreement of the heads of both cardiology and cardiothoracic surgery departments before admitting any new patient. 12 9 CABG, coronary artery bypass graft 

World Health Organization. Coronavirus disease (COVID-19) outbreak

Fast reshaping of intensive care unit facilities in a large metropolitan

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Protecting High-Risk Cardiac Patients During the COVID-19 Outbreak

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