key: cord-0825438-vchslppw
authors: Cerillo, Alfredo G.; Marchionni, Niccolò; Bacchi, Beatrice; Stefàno, Pierluigi
title: COVID‐19 in patients recovering from cardiac surgery: A surprising mild disease course
date: 2021-01-13
journal: J Card Surg
DOI: 10.1111/jocs.15326
sha: 9fe222bc544a2ac17da2f8586ee080390ab968c2
doc_id: 825438
cord_uid: vchslppw

BACKGROUND: We describe the baseline, operative, and postoperative features of a group of 18 patients who contracted the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infection in a rehabilitation facility after cardiac surgery, and present some potential explanations for the surprisingly benign course of the COVID‐19 in this cohort. METHODS: All patients were operated on an urgent or emergency basis (acute aortic syndrome, 3; refractory heart failure, 12; and endocarditis, 3) during the first lockdown period of the COVID‐19 pandemic. The mean age was 70 years, and 12 patients were male. After the diagnosis of COVID‐19, patients were treated according to the most recent recommendations. Eleven asymptomatic patients were discharged home or to a COVID‐19 hotel and underwent close monitoring. Patients with fever, dyspnea, or a significant rise of the polymerase chain reaction levels were hospitalized, three received antivirals, three azithromicyne, and five hydroxychloroquine. Nasal swabs were repeated on a weekly basis, and all patients were quarantined until the collection of two consecutive negative samples. RESULTS: Diversely from other observations on perioperative COVID‐19 reporting mortality rates of 30%–40%, the COVID‐19 had a benign course in our cohort: only seven patients required hospitalization, and one required short intensive care unit admission. There were no deaths, and at the latest follow‐up, all patients had been discharged home. COMMENT: Our data show that the SARS‐CoV2 infection after cardiac surgery may have a benign course. Further studies are needed to investigate the relationship between the timing of the infection, some potentially protective therapies (e.g., anticoagulants), and the course of the COVID‐19.

The preoperative clinical features, the surgical details, and the postoperative outcome and complications are reported in Table 1 . As can be easily appreciated, this was a group of critically ill, elderly patients with multiple severe comorbidities and high surgical risk scores. Twelve patients were male, and the mean age was 70 years.

Only four patients who were all operated on an emergency basis for critical, high-risk conditions (two for aortic dissection and two for bacterial endocarditis) were younger than 70.

The indications to urgent/emergency surgery were as follows:

aortic dissection/pathology of the ascending aorta (three), refractory congestive heart failure for aortic (four) mitral (three), or multiple (three) valve disease, combined valvular and ischemic heart disease (two), acute endocarditis (two), and syncope in hypertrophic obstructive cardiomyopathy (one). During the early postoperative course, seven patients had atrial fibrillation and two patients required re-exploration for bleeding. Two patients had a transient increase of the creatinine levels, three needed inotropic support, and three required prolonged ventilatory assistance. One patient developed a complete heart block and underwent pacemaker implantation.

The median interval between the operation and the discharge to frequent and associated with increased mortality. In the subgroup of 51 cardiac surgical patients, the incidence of pulmonary complications was as high as 94.1%, and the mortality was 34%. 3 Yates et al. 4 reported similar results: all their patients had pulmonary complications, the postoperative hospital stay was prolonged, and the mortality was 44.4%. Considering all these data, the benign course of the COVID-19 in our patients might appear paradoxical.

A first, possible explanation of this paradox is stochastic: given that the true prevalence and mortality rate of the SARS-CoV2 infection is not known, it is possible that the low rate of symptoms and complications was simply due to chance. Indeed, all patients-not only those with a clinical suspect of COVID-19-were tested in the rehabilitation clinic, and this could have maximized the sensitivity of the screening program. However, the prevalence of severe comorbid chronic diseases and risk factors was extremely high in our cohort, increasing the theoretic risk of a severe COVID-19. In fact, data from other series of perioperative COVID-19 in cardiac surgery showed ubiquitous pulmonary complications and very high mortality rates. 3, 4 An attractive hypothesis is that our patients were somehow "protected" from the COVID-19. All our patients received lowmolecular-weight heparin during the perioperative period, and all except one were discharged on oral anticoagulants. Altered hemostasis plays a major role in the development of severe COVID-19, and anticoagulants might have exerted a protective effect. 5

Severe COVID-19 is characterized by the development of ARDS, which eventually leads to ICU admission and death. 6 A maladaptive immune response involving activation of the innate immunity has been indicated as the pathogenetic mechanism of ARDS. Cardiac surgery promotes a strong systemic inflammatory response. 7 It is possible that the recent activation of the innate immunity related to the surgical stress caused a secondary immunodeficiency in our patients, resulting in a blunted immune response to the SARS-CoV2 infection.

While the potential protective role of a blunted immune response and/or of the anticoagulant therapy may only be speculated, our population offers an interesting view on a delicate aspect of the COVID-19 pandemic, that is, the occurrence of a cluster of infections in a group of high-risk hospitalized patients. Eighteen out of 19 exposed patients were infected, highlighting the contagiousness of the disease. 

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COVID-19 in patients recovering from cardiac surgery: A surprising mild disease course

This is a single institution, observational study on a small group of