Cardiac surgery in patients with confirmed COVID-19 infection: Early experience.

The novel coronavirus, now termed SARS-CoV-2, has caused a significant global impact in the space of 4 months. Almost all elective cardiac surgical operations have been postponed in order to reduce transmission and to allocate resources adequately. Urgent and emergency cardiac surgery is still taking place during the pandemic. The decision to operate in urgent patients with active/recent COVID-19 infection is difficult to make, particularly as it is still an unknown disease entity in the setting of emergent cardiac surgery. We present a case series of three patients who underwent urgent cardiac surgery and who have had recent or active COVID-19 infection.

INTRODUCTION

The novel coronavirus, now termed severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has caused a significant global impact on the economy, politics, and health in the space of 4 months. Almost all elective cardiac surgical operations have been postponed with only urgent and emergency operations being performed globally. The prevalence of coronavirus disease‐2019 (COVID‐19) in patients with underlying cardiovascular disease is under‐reported with evidence that preexisting cardiac disease can render patients more vulnerable to the disease process. The decision to operate in urgent patients with active/recent COVID‐19 infection is difficult to make as it is an unknown disease entity with outcomes of emergent cardiac surgery difficult to predict. We present a case series of three patients who underwent urgent cardiac surgery who have had recent or active COVID‐19 infection.

CASE 1

A 44‐year‐old gentleman presented to hospital with worsening shortness of breath and presyncope on minimal exertion. Clinical examination suggested aortic stenosis and past medical history was significant for type 1 insulin‐dependent diabetes mellitus, recurrent osteomyelitis, and excess alcohol consumption. Transthoracic echocardiogram confirmed severe aortic stenosis in a bicuspid valve (Vmax 4.36 m/s, aortic valve area 0.78 cm2, PG 76 mm Hg, and mean transaortic gradient 40 mm Hg) with an impaired left ventricular (LV) function (35%). Chest roentgenogram revealed bilateral pleural effusions. He tested positive for COVID‐19 and was kept isolated for a further 2 weeks without developing any serious clinical manifestations of COVID‐19 infection. During this time period, the patient was also considered for transcatheter aortic valve implantation. However, his computed tomography (CT) aortogram deemed the anatomy unfavorable with a high risk of complications. Repeat 48‐hourly COVID‐19 testing 3 weeks after referral revealed six positive results despite full clinical recovery, with only one negative result in between. A CT thorax reported signs of acute pulmonary edema with no features of COVID‐19 pneumonia. Given the worsening LV function and breathlessness, it was decided that surgical treatment of his valve could not be delayed until the end of pandemic. He underwent a surgical tissue aortic valve replacement (due to his alcohol excess and likely lack of compliance with Warfarin). Full personal protective equipment was donned and a standard median sternotomy performed. Cardiopulmonary bypass was established via the ascending aorta and right atrium. A severely calcified bicuspid aortic valve was replaced with a 21 mm St. Jude Trifecta pericardial valve using interrupted pledgetted sutures. The patient had an uneventful postoperative course and was discharged on the 8th postoperative day.

CASE 2

A 68‐year‐old gentleman presented to hospital with fevers, lethargy, and recent onset back pain. Clinical examination revealed a diastolic murmur and he was febrile. His past medical history was significant for prostate cancer and type‐2 diabetes mellitus. Blood cultures revealed Enterococcus faecalis and he was started on empirical intravenous antibiotics (gentamicin and co‐amoxicillin). Magnetic resonance imaging spine was suspicious for discitis at C5‐C6. Transthoracic echocardiogram was unable to exclude infective endocarditis. However, subsequent transesophageal echocardiogram revealed multiple mobile vegetations on the native aortic valve, with the largest vegetation measuring 11 mm. COVID‐19 swab test was positive on admission, but he displayed no overt clinical signs of respiratory compromise. CT thorax suggested a small aortic root abscess between the left and right Valsalva sinuses but no lung parenchymal changes suggestive of COVID‐19. The patient remained on intravenous antibiotics whilst the decision to operate was delayed until the following two consecutive COVID‐19 swabs were negative 48 hours later. He subsequently underwent an urgent mechanical aortic valve replacement. Full personal protective equipment was donned and a standard median sternotomy performed. Cardiopulmonary bypass was established via the ascending aorta and right atrium. A tricuspid valve with multiple vegetations was removed with no evidence of a root abscess. The aortic valve was replaced with a 23 mm CarboMedics mechanical aortic valve using interrupted pledgetted sutures. The patient had an uneventful postoperative course and was discharged on the 7th postoperative day.

CASE 3

A 60‐year‐old gentleman presented with an out of hospital cardiac arrest. Bystander cardiopulmonary resuscitation was given by his wife, followed by shocks administered by the ambulance crew, with a downtime of 10 minutes. His medical history was significant for hypertension but he was otherwise fit and well. Urgent coronary angiogram revealed a short left main stem, severe ostial left anterior descending (LAD) disease with mid‐LAD occlusion, severe ostial circumflex disease, and severe right coronary disease. Balloon angioplasty to suspected lesions performed with moderate improvement in flow. Transthoracic echocardiogram revealed a moderately impaired left ventricle with mild central mitral regurgitation. He was initially treated in the intensive care unit with minimal respiratory support and was discharged to the ward the following day. He tested positive for COVID‐19 after displaying mild symptoms of breathlessness on the ward. CT thorax revealed extensive patchy and ground‐glass changes highly suggestive of COVID‐19 pneumonia (Figure 1). He remained isolated and treated conservatively with minimal respiratory support on the ward. He made a good clinical recovery and two further COVID‐19 swabs a week later were confirmed negative. Repeat chest radiography showed a significant improvement. He underwent coronary artery bypass graft surgery during this hospital admission. Full personal protective equipment was donned and a standard median sternotomy performed. Cardiopulmonary bypass was established via the ascending aorta and right atrium. Left internal mammary artery and long saphenous vein was harvested as conduits. The patient had an uneventful postoperative course and was discharged on the 5th postoperative day.

Figure 1

A, CT chest showing extensive patchy consolidation and ground‐glass opacities in case 3. B, Chest X‐ray of case 3 on day before surgical operation showing resolution. C, Transesophageal echocardiogram showing vegetations on the aortic valve leaflets in case 2. CT, computed tomography

DISCUSSION

The decision to operate on emergent cardiac surgical patients with active or recent COVID‐19 infection is difficult to make during an evolving pandemic. COVID‐19 is as of yet an unknown disease entity with varying clinical manifestations and the outcomes of cardiac surgery are even less defined. Our three cases illustrate some of the complexities in decision making that would otherwise have been routine in a pre‐COVID era.

The first case highlights a relatively straightforward presentation of severe aortic stenosis mandating urgent inpatient surgery. Although he had one negative reverse transcription polymerase chain reaction (RT‐PCR) swab test, all other swab result before and after this were positive. This should not come as a surprise as the current test has been reported to have a high false negative result. Current, albeit anecdotal advice, is to wait for at least two consecutive negative results before considering operative treatment. However, this proved difficult in our patient, who although completely asymptomatic, was still testing positive 5 weeks later. A joint multidisciplinary meeting involving cardiology, anesthesiology, and infectious diseases advised to proceed with the operation in full protective gear and with all the necessary precautions. The infectivity and contagious period of asymptomatic patients with persistently positive SARS‐Cov2 RNA is unknown and yet to be established; they are currently still being treated as infectious and active. Furthermore, the effects of cardiopulmonary bypass in a patient with presumably active COVID‐19 infection is unknown with clinical urgency taking priority in this case.

The second case in our series was again asymptomatic but tested positive on RT‐PCR COVID‐19 testing. Our institution now mandates that all cases provisionally listed for surgery should undergo testing to risk stratify patients. All urgent patients requiring cardiac surgery need to be intubated and ultimately require intensive care support in the immediate postoperative period. The absence of a COVID‐19 test preoperatively would put attending staff and nearby patients in the unit at unjustifiable risk. Furthermore, it is still unclear which cohort of patients that test positive go on to develop the full clinical manifestation of the disease. As such, we believe that operating on COVID‐19 positive patients based on the initial symptoms in the first few days alone, would not be in the patient's best interest. Initial studies have suggested that symptoms and clinical deterioration can occur up to 10 to 14 days after contraction. However, consecutive negative results and clinical stability would favor operative treatment earlier than this time period.

Our third case highlights the importance of a CT thorax as part of our routine preoperative cardiac surgical workup during this pandemic. Recent studies have suggested that CT changes may even precede RT‐PCR findings and clinical signs of COVID‐19. Extensive patchy consolidation and ground‐glass changes suggestive of COVID‐19, warranted an extended period of observation in hospital in this case. Although this patient did not require significant respiratory support, it was important that his respiratory reserve was optimized before urgent surgery. Serial chest X‐ray's showed a remarkable improvement in this case before being listed for surgery.

Our cases highlight the difficult decision making process in unprecedented times. The role of cardiac surgery in the presence of COVID‐19 is still yet to be determined and long terms outcomes are clearly warranted.

CONFLICT OF INTERESTS

All the authors declare that there no conflict of interests.

ETHICAL STATEMENT

Local IRB guidance was followed. All patients were consented.