Reply: Have we done the best that we could have done?

Reply to the Editor:

Dr Arora holds an unrestricted educational grant from , Inc, and Honoraria from , , and unrelated to the present communication. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

In their letter to the editor, Maj and colleagues cited the recently published guidance document on cardiac surgical triaging during the coronavirus 2019 (COVID-19) pandemic by Haft and colleagues and raised the following points: (1) the absence of patient frailty as part of the triaging process, (2) the potential collateral impact of deferring patients on the cardiac surgery wait list during the pandemic, and (3) the value of routine preoperative COVID-19 testing in protecting both patients and health care workers.

First, frailty is a well-established risk factor for increased morbidity and mortality following cardiac surgery. The recently-published National Institute for Health and Care Excellence (NICE) guidelines have incorporated a measure of frailty to guide clinical decisions in critically ill adults. We acknowledge that frail patients are likely at increased risk for contracting COVID-19 (with an as of yet-to-be determined impact on outcomes) and that frailty should be considered when triaging patients both during the surgical deferral phase of the pandemic and as part of the “ramping back up” phase when the COVID-19 curves begin to flatten.

Second, delay in definitive therapy for certain cardiovascular diseases may yield major adverse cardiac consequences, including myocardial infarction, decline in ventricular function, or sudden death. As such, we must re-emphasize that for those patients in whom procedures are being delayed and in whom alternative therapies are not deemed appropriate, there is a critical need to proactively monitor every patient on the surgical wait-list for progression of symptoms.

Finally, we are saddened by Maj and colleagues' accounts of COVID-19 infection at their institution, first in those patients with advanced cardiovascular disease who, despite not having viral symptoms on admission, eventually tested positive for COVID-19, and second, among the cardiac surgeons, cardiac anesthesiologists, and nurses who tested positive while serving on the frontlines. Many have advocated for routine testing in an effort to mitigate the risk of COVID-19 infection and transmission, but there remains, at present, NO test available that can reliably rule out COVID-19, particularly in the asymptomatic patient. Rather, testing must be complemented by well-established risk-reduction strategies, including frequent screening, handwashing, physical distancing, use of personal protective equipment, and isolation of those at risk. Only then will hospitals be able to provide a safe environment for their patients and their health care providers in the “post-lockdown, pre-vaccine” phase of the pandemic.

Cardiac surgeons from across the world have drastically changed their clinical practices in response to the COVID-19 pandemic, and while published guidance statements have provided a template by which these changes could be carried out, they have not always accounted for the differences that often exist between institutions, regions, and countries. The letter by Maj and colleagues highlights the realities that some of us face, and it is up to the global cardiac surgical community to share knowledge, experiences, and collect data to determine best practices so that we may care for our patients and for each other to the best of our abilities.