key: cord-0695584-r711cdgn
authors: Mohamed Abdel Shafi, Ahmed; Hewage, Savini; Harky, Amer
title: The impact of COVID‐19 on the provision of cardiac surgical services
date: 2020-05-17
journal: J Card Surg
DOI: 10.1111/jocs.14631
sha: b56043cc4a991c6cd019570799a0a4099a019eb8
doc_id: 695584
cord_uid: r711cdgn

The global pandemic caused by COVID‐19 has had a significant global impact on healthcare systems. One implication of this pandemic is the cancellation of elective cardiac surgeries and the centralization of services. As a result, hospitals in Europe, North America, and the United Kingdom have had to alter the services offered to patients to be able to cope with service provision for COVID infected patients. Data should be collected during this period to provide a good insight following the lockdown period to understand the implication of such service alteration. Future research should also focus on the effects on long‐term mortality and morbidity as well as financial implications on hospitals as a result of these changes.

In the UK, the government introduced emergency legislation for a UK wide lockdown on 23rd March 2020 in an attempt to contain the spread of the virus, following examples from other countries. During the lockdown period, the activities of cardiac surgery have been significantly affected.

With the exponential increases in COVID-19 cases seen, and the dramatic burden this has had on the healthcare system, intensive care resources have needed to be reallocated to deal with the accelerating burden that COVID-19 poses. As a result, this pandemic has resulted in a shortage of ventilators, intensive care beds, personal protective equipment, and staff in the workforce of the healthcare system. Cardiac surgery, which is heavily dependent on intensive care resources, has undergone dramatic changes with services becoming centralized in an attempt to continue to provide a cardiac surgical service during these unprecedented times, similar to that in Italy.

Daily multidisciplinary team meetings are being performed to identify patients that need surgical intervention either as urgent or emergency cases with particular attention being given to COVID testing (including swabs and routine COVID CT scan of the thorax).

Patients on elective waiting lists with pathology deemed unsuitable to be delayed by 2 to 3 months are also being prioritized. 

The literature has highlighted two significant issues concerning COVID-19 and cardiovascular disease, in that 15% of patients with COVID have established cardiovascular comorbidities, and emerging evidence shows that preexisting cardiac disease is an important risk factor for developing more severe infection. 2, 3 Another concern is that preexisting coronary artery disease and patients with risk factors for atherosclerotic disease are at an increased risk of developing acute coronary syndromes during acute infection, which has been established in previous epidemiologic and clinical studies. [4] [5] [6] [7] The cardiac surgical patient population is more susceptible to developing severe complications related to COVID-19 infection. The pathophysiological effects of COVID-19 are slowly being unraveled and have been shown to induce multiple cytokines and chemokines that result in vascular inflammation, plaque instability, and myocardial inflammation. 8 This poses an increased risk in terms of the postoperative period of patients undergoing cardiac surgery, which is characterized by a proinflammatory state.

In terms of the effect this has had in Europe, if we look at Italy which is one of the worst affected counties, they reported that 12.8% and 20.2% COVID-19 related mortality occurred in the age group of 70 to 79 and over 80s respectively, 9 which represents the patient demographics often necessitating cardiac surgery. The strain on healthcare resources is also well established despite efforts to increase hospital and intensive care capacity, with over 64% of hospital beds and 88% of intensive beds allocated to treat COVID-19 patients. 10 Italy has also canceled elective surgery and has made dedicated cardiac centers, for example, the Lombardy region has had 16 of the 20 cardiac centers discontinue the activity and centralized to the remaining four centers in a "Hub and Spoke" model. With the "Hub" centers responsible to provide urgent and emergency cardiac services, with sharing of surgical teams across the 20 hospitals to facilitate shift organization, allowing teams from different centers to be on call. 11 Canada has also had to adapt, by prioritizing and delaying elective cases. The cardiac surgeons, together with members of the heart team, have also had to reconsider best management strategies for these patients. They have proposed strategies to utilize the use of virtual clinics to follow-up patients and have attempted to maintain areas for cardiac surgery separate from COVID-19 where feasible. 12 

Studies have already established that patients with cardiovascular disease are at an increased risk of developing severe COVID-19 infection. 2 Studies in China, the epicenter of the COVID-19 outbreak, have also demonstrated the relationship between myocardial injury due to COVID-19 and high mortality. 13, 14 In the UK there are several studies, that are in the data collection stage, which are focused on different aspects of how COVID-19 has impacted cardiac surgery and its surgical resources. COVIDSurg is an international database that has started in Birmingham, UK, and registered as a clinical trial (NCT04323644) focusing on collecting data on COVID-19 patients that are undergoing surgery and its due to complete by September 2020. We hope that such data will provide an insight into patient cohorts in this pandemic era. Furthermore, there is

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