Response of Cardiac Surgery Units to COVID-19: An Internationally-Based Quantitative Survey.

The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented global effect on health care. We quantified the experience and changes implemented in response to the COVID-19 pandemic across cardiac surgery centers participating in an international research consortium.

A 40-question questionnaire was e-mailed to all centers participating in the international ROMA trial (Randomized Comparison of the Outcome of Single Versus Multiple Arterial Grafts)[1] on March 23, 2020. Participation was voluntary and anonymized. The questionnaire assessed each center’s pandemic response according to regional disease prevalence; local resources and logistics; and institutional, regional, or national policies. The numbers of infections by country were obtained from the Johns Hopkins Coronavirus Resource Center[2] and adjusted by population size per million inhabitants. We used incidence data contemporary to the date of surveys compilation. Correlations between the adjusted number of COVID-19 infections and survey variables were calculated using the Pearson correlation coefficient. The study did not require institutional review board approval.

Of the 61 centers approached, 60 (98.3%) completed the survey: 7 from Asia, 2 from Australia, 31 from Europe, 16 from North America, and 4 from South America. Of the survey responses, 57 out of 60 (95%) came from cardiac surgeons holding an administrative leadership position at their center. The median reduction in cardiac surgery case volume was 50% to 75%, correlating with the number of local of COVID-19 cases (correlation coefficient [r]=0.36; P<0.001). A third of the centers reported >50% reduction in the number of dedicated cardiac operating rooms and intensive care unit beds. Most centers restricted cardiac surgery activity to urgent and emergent cases; 5% had canceled all cases including emergencies. Almost a third of the centers relocated personnel to other departments; the majority was relocated to the intensive care unit, highly correlating (r=0.86, P<0.001) with the local number of COVID-19 infections. Half of the centers still permitted fellows and residents to participate in cardiac surgeries, and about half had suspended all research activity. There was no significant difference between continents with respect to relocation of personnel or suspension of cardiac surgery research. South American centers reported lesser reductions in cardiac surgery case volume (P=0.02). Asian centers more frequently were performing elective surgery (P=0.03).

There was no statistically significant difference between low- (≤25th percentile) and high-volume (≥75th percentile) centers in terms of case volume reduction, personnel relocation, suspension of research, or allowed cardiac surgery activity. Most centers discussed ethical issues around decision making during a surge that would overwhelm all healthcare services. Almost all centers instituted protocols to restrict visitors to their cardiac surgery unit, and one third continued to perform in-person patient follow-up. A majority of centers anticipated that the restrictions preventing full cardiac surgery activity would last >1 month (Table).

This survey of 60 cardiac surgery centers (comprising 618 cardiac surgeons) across 19 countries provides a unique description of the cardiac surgery response to the COVID-19 pandemic worldwide. Most of the respondents to our survey were in the advanced phase of the pandemic with >1000 local infections.[3] Although COVID-19 patients accounted for fewer than 10% of hospital inpatients at the centers surveyed, almost two-thirds of centers reported a reduction of greater than 50% in intensive care bed availability for cardiac surgery patients, which may reflect the prolonged ventilator dependence characterizing 20% to 30% of hospitalized patients with COVID-19.[4] In more than a third of centers, cardiac surgery personnel were redeployed to care for patients with COVID-19. Respondents reported a median reduction in cardiac surgery case volume by 50% to 75%. The negative effects of such suspension of all elective cardiac surgeries are unclear at the moment; however, data from healthcare systems where surgery is routinely deferred because of limited capacity have shown increased operative mortality in patients who are on a cardiac surgery waitlist.[5]

Furthermore, the reduction in research activity reported by more than 50% of the centers could jeopardize the ability to promptly collect and analyze key information on the consequences of the COVID-19 crisis. A reduction in educational activity is also of concern, particularly in countries such as the United States, where cardiac surgical training is limited to 1 or 2 years.

Our study has limitations; it is a snapshot of a rapidly evolving situation, affecting heterogeneous populations with variable responses during the pandemic. Survey responses are inherently prone to subjectivity. Survey participants were drawn predominantly from large cardiac surgery centers, and responses may not reflect those of smaller community programs.

To conclude, the majority of the respondents to our survey reported reduced cardiac surgery activity, redeployed personnel, and curtailed educational and research activities in response to the COVID-19 pandemic. The widespread interruption in cardiac surgery described herein adds to the concerning observation that excess mortality not related to COVID-19 infections may now surpass mortality directly related to COVID-19 infections. Our data may also help inform the responses to the subsequent phases, if any, of this pandemic.

Acknowledgments

The authors thank the Cornell Joint Clinical Trial Office for their support in this project.

Disclosures

None.

Table.

Status of Responding Centers During the COVID-19 Pandemic