Preoperative COVID-19 Testing for Cardiovascular Procedures in Endemic Areas Should be Mandatory.

THE 2019 CORONAVIRUS infectious disease (COVID-19), caused by the virus SARS-CoV-2, has resulted in the death of more 630,000 patients worldwide and has greatly impacted both medicine and society. Two main clinical manifestations in patients with COVID-19 are acute respiratory distress syndrome (ARDS) and thromboembolic events from an induced hypercoagulable state. In order to accommodate for surges in COVID-19 cases, medical centers across the globe have canceled or severely limited nonemergent surgical cases. As institutions cautiously reopen and initiate elective surgeries, preoperative testing is an important topic for patient and provider safety. Preoperative testing for COVID-19 in cardiovascular procedures should be performed to detect asymptomatic patients in order to reduce harm, protect healthcare providers, and for epidemiologic reasons, such as contact tracing for infected healthcare providers.

The main clinical manifestations of COVID-19 are respiratory failure due to ARDS and thromboembolic phenomena from a hypercoagulable state. Multiple retrospective reviews of COVID-19 positive patients suggested a high perioperative morbidity and mortality (up to a 48.3% rate of pulmonary complications and a 21.1% risk of mortality).3, 4, 5 In a cohort of 3,334 patients, the incidence of a thromboembolic event was 16% and more commonly arterial, with an 8.9% incidence of myocardial infarction. A subgroup analysis of this work found a 29.4% incidence of thromboembolic events in critically ill patients and 11.5% in noncritically ill patients. In patients undergoing cardiovascular surgical procedures, these statistics would underrepresent perioperative complications given the hypercoagulable state from inflammation and the comorbidities of this patient population. In surgery involving cardiopulmonary bypass, a retrospective review of cardiac surgery during influenza season found a 9% risk of postoperative ARDS versus a 5.1% risk when not in the influenza season; duration of postoperative intubation was also longer during the influenza season. Though not the same virus, it is almost certainly the case that cardiac surgery involving cardiopulmonary bypass in COVID-19 patients would result in a higher risk of ARDS and poor outcomes as well. In 2017, there were 292,500 cardiac surgical cases entered into the Society of Thoracic Surgeons adult cardiac surgery database. If even 1 percent of these patients were preoperatively diagnosed with COVID-19 (2,925 patients), then a great impact on patient safety may be achievable by postponing surgery, if feasible. Finally, if a COVID-19- positive patient must undergo surgery, knowledge of the positive test can assist with postprocedural patient placement.

Healthcare provider safety is an important consideration during the COVID-19 pandemic. Aerosol- generating procedures, including intubation, transesophageal echocardiography, and bronchoscopy, are frequently performed in patients undergoing cardiovascular procedures.9, 10, 11 Minimizing unnecessary exposure to patients with COVID-19 is a very important consideration for the large team of providers present during cardiovascular procedures. Despite a suboptimal sensitivity, a negative test in conjunction, with negative symptoms, serve to minimize the risk of performing nonemergent procedures on patients with COVID-19. Regardless of test results, N95 masks and eye protection should be used by all individuals in the room of a patient undergoing an aerosol- generating procedure. ,

Preoperative testing for COVID-19 is also important for epidemiologic purposes. Multiple countries, including China and South Korea, have had resurgences of COVID-19 after apparent lulls in infection rates, and these resurgences are challenging to predict. Testing before major procedures can minimize the risk to patients with subclinical infection that may be made worse from the stresses of surgery and anesthesia. Another reason to test patients is for contact tracing in healthcare providers; many procedural suites have multiple patients per day despite having the same teams. In an institution that performs 1,000 cases per month, even a prevalence of 0.5%% to- 1.0% of asymptomatic COVID-19 patients exposes many periprocedural healthcare providers to potentially infectious circumstances. When outbreaks among healthcare providers occur, it is difficult to retroactively test all patients they treated, making contact tracing extremely difficult. Finally, a positive test allows the individual to quarantine and minimize the community spread of infection, as well as preventing them from infecting others in hospital preoperative areas and other high population density locations.

In summary, periprocedural testing for patients presenting for cardiovascular procedures is extremely important to minimize respiratory complications and thromboembolic events, as well as to reduce the risk of mortality in this high-risk patient population. Minimizing healthcare provider exposure to COVID-19-positive patients reduces the risk of transmission to front-line workers. Preoperatively testing patients will simplify contact tracing in the case of healthcare worker outbreaks in addition to allowing patients to quarantine and minimize community and nosocomial spread. It is extremely important for patients, healthcare providers, and the community at large to aggressively test for COVID-19 in the preprocedural period when the infection is endemic. A thoughtful discussion on de-escalation should only occur with sustained control of the infection, the duration of which is not clear at the present time.

Conflict of Interest

None.