Cardiothoracic Surgery at the Time of the Coronavirus Disease-2019 Pandemic: Lessons From the East (and From a Previous Epidemic) for Western Battlefields.

THE CORONAVIRUS DISEASE 2019 (COVID-19) outbreak that spread from Wuhan, China, in December 2019 became a global pandemic within about 2 months, causing more than 330,000 deaths worldwide so far (at the time of writing). This has forced hospitals in the most affected countries and regions around the world to rearrange their activity, creating new spaces and pathways while reducing nonurgent admissions and health services. Although only a minority of patients infected with the new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) develop symptoms severe enough to require intensive care unit (ICU) admission, the wide diffusion of contagion led to a very high absolute number of patients admitted to the ICU (about 90% of whom required tracheal intubation and invasive mechanical ventilation), thus overwhelming the usual numbers of ICU beds and mechanical ventilators of national/regional health systems and forcing hospitals to draw resources from other clinical settings such as elective surgery. On the other hand, stopping nonurgent hospital admissions and postponing elective surgical interventions is also pivotal to limit contagion within hospitals.

However, there are healthcare activities that can neither be stopped nor greatly reduced, and cardiothoracic surgery definitely is among them. Indeed, apart from diseases that require urgent/emergent surgical treatment (eg, aortic dissection, thoracic trauma, endocarditis, intracardiac tumors, etc), 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 asymptomatic infection.

In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, a special article by Tan et al. described 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 reported 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 included: 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 rooms (as well as the ability to keep the operating room doors closed for at least 10 minutes after tracheal intubation or extubation 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 elevators) 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 to prevent cross-contamination among healthcare personnel if 1 surgical team should be accidentally exposed to a patient with asymptomatic 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 China, but some of them are still difficult (if not impossible) to implement in many Western countries that have now far exceeded the number of Singapore cases and casualties. Evidently, countries that faced the severe acute respiratory syndrome (SARS) outbreak, the first coronavirus pandemic of the current century that affected more than 8,000 people (mainly in China, Vietnam, Singapore, and Canada) in 2003, were much more prepared, both culturally and in terms of facilities and equipment, 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). However, maybe also due to the particular geographic and economic features of Singapore, the response to the current health emergency implemented at the Singapore National Heart Centre appeared to be particularly punctual and comprehensive even compared with the protocols (though detailed and certainly adequate according to the local conditions) adopted in hospitals of other countries that were highly affected by the 2003 SARS epidemic , , 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. 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, compared with 3,252 cases (and 10 deaths) in Singapore. The 2 hospitals in which the authors work are in the front line 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 the authors’ centers remained rather significant.

Table 1

Number of Cardiothoracic ICU Admissions and of Cardiac Surgery Procedures From March 1 to 31, 2020, at San Raffaele Hospital (Milan, Northern Italy) and Monaldi Hospital (Naples, Southern Italy)

	San Raffaele Hospital, Milan	Monaldi Hospital, Naples
Cardiothoracic ICU admissions, n*	58	68
Cardiac surgery procedures, overall, n	46	47
Cardiac surgery procedures, for type of intervention, n†
CABG, n	10	22
Valve replacement/repair, n‡	25	21
Aortic surgery, n	4	5
Others, n§	12	9

CABG, coronary artery bypass graft; ICU, intensive care unit.

In both hospitals, the 14-bed cardiothoracic ICU (San Raffaele) and the 11-bed cardiac surgery ICU (Monaldi) also admitted non-cardiac-surgical patients needing intensive care from the beginning of the national health emergency.

Combined procedures are listed in all pertinent subgroups.

Including transcatheter aortic valve replacement (TAVR) and MitraClip procedures.

Including cardiac tamponade drainage, myxoma removal, sternal revision, wound closure, mechanical circulatory assistance implantation/removal, and pleuropericardic window.

Given the widespread contagion (whose extent is likely largely underestimated due to the hypothesized high number of asymptomatic or mildly symptomatic infections , ), 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 and especially among patients whose comorbidities and clinical conditions possibly predispose them to worse outcomes after SARS-CoV-2 infection. Indeed, the same features of the COVID-19 disease that 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); the possible person-to-person transmission from asymptomatic individuals or even in either the prodromal or convalescence phase of the disease; the suggested significant percentage of false- negative results with nasal swab testing (approximately 1 in 3); and the high estimated number of asymptomatic infections itself.

Most hospitals (including those where the authors work) are adopting important measures to limit contagion among patients and healthcare workers, such as reducing nonurgent admissions and surgical activity, limiting visitors, trainees, and students’ access, performing staff surveillance (through either temperature recording or laboratory screening), requiring nasal swab for signs of SARS-CoV-2 before patients are transferred from other hospitals or performing it at admission, and using surgical masks all the time and anywhere in the hospital. In addition to these measures, Tan and colleagues reported other important measures that, 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 those 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 the cardiology and cardiothoracic surgery departments before admitting any new patients.