Commentary: To operate or wait? Contextualizing early outcomes of cardiac surgery in COVID-19-positive patients.

Sameer A. Hirji, MD, MPH (left), Cheryl K. Zogg, PhD, MSPH, MHS (middle), and Tom C. Nguyen, MD (right)

COVID-19 infection increases the risk of cardiac surgery, and caution is warranted to balance operative need with safe procedures during a patient's entire disease course.

See Article page e355.

The global outbreak of SARS-CoV-2 led to widespread disruption of elective surgical procedures. In the context of cardiac surgery, it dramatically reduced the nationwide operative case volume by more than 50% and created a backlog of deferred cardiac surgeries, according to recent data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD). As a consequence, hospitals are left to grapple with how best to prepare for “postpandemic planning” in the midst of infection while simultaneously facing an increasing number of patients forced to prolong their disease course and wait. In their brief communication in this issue of the Journal, the Cardiothoracic Interdisciplinary Research Network and COVIDSurg Collaborative seek to help hospitals address this issue by studying the outcomes of 155 preoperatively and 52 postoperatively diagnosed cases of COVID-19 patients who underwent cardiac surgery between March 1 and July 31, 2020. The study found no significant difference in the incidence of mortality (15.4% vs 21.9%) or major morbidity (except pneumonia: 28.8% vs 46.6%) between COVID-19 patients diagnosed within 7 days of surgery compared to 30 days after surgery—a finding that led them to argue for the importance of ensuring that adult cardiac surgery patients are managed postoperatively on “COVID clean” pathways and wards to minimize the risk of postoperative infection and related sequalae.

We commend the work coordinated by the COVIDSurg Collaborative in collecting this vital information from their multicenter cohort. These results represent one of the largest case series of cardiac surgery outcomes among COVID-19–positive patients published to date, offering important insights into the need to minimize the perioperative risk of SARS-CoV-2 infection. It builds on prior work from the COVIDSurg Collaborative, which showed that among all COVID-19–positive patients, delaying surgery by ≥7 weeks after SARS-CoV-2 diagnosis was associated with reduced mortality back to preinfection levels. Both studies suggest that operating on a COVID-19–positive patient increases the patient's risk of death. , These findings are also corroborated in the recent analysis of the STS ACSD, which showed a 110% increase in the odds to expected ratio for all adult cardiac procedures during this study period.

As hospitals begin reopening operating room doors to the mounting backlog of patients awaiting elective procedures, guidelines from organizations like the STS and the American Association for Thoracic Surgery (AATS) may offer a reasonable approach centered around the importance of protecting the cardiac patient, the institution and society at large, and the health care team. Modeling studies from throughout the pandemic have further emphasized that it will take time for hospitals to clear their backlog, depending on their respective operative capacity in the post-COVID period and the potential consequences that waiting could have on patients requiring more urgent operative care. We believe that a stepwise/tiered reopening approach that focuses on minimizing infection risk is prudent and will simultaneously ensure that patients in need of care are not endlessly caught in the crosshairs of surgeons' and hospitals' struggle with how best to answer the difficult question of when is the right time to operate or wait.