Commentary: Surgical emergencies don't quarantine.

N. Bryce Robinson, MD, and Mario Gaudino, MD

As the COVID-19 pandemic continues to impact countries worldwide, strategies must be developed to allow for continued care of patients who present with other emergent pathologies.

See Article page 50 in the December 2020 issue.

We read this short communication by Professor Davide Pacini and colleagues with great interest. The authors summarize their experience with acute type A aortic dissection (ATAAD) as 1 of the 4 cardiac surgery “hub” centers during the height of the coronavirus disease 2019 (COVID-19) pandemic in Bologna, Italy. It comes as no surprise that surgical volumes fell during the study period by an estimated 30% when compared with 2019 volumes. Perhaps more concerning is that during the acute lockdown in March, only 2 patients presented with ATAAD, compared with 10 in April toward the end of the lockdown. As the authors suggest, this is likely secondary to the fear patients had of leaving their homes or interacting with the health care system, especially in the absence of companions as visitation was prohibited during the lockdown. Furthermore, of the 10 patients who presented in April, 60% had signs of malperfusion again suggesting a delay in presentation, with 3 patients dying before surgical repair. The mean time from symptom onset to evaluation was 10.3 hours, more than double the rate reported in the literature. The authors are to be commended on their excellent outcomes in the patients who underwent successful operative repair in unprecedented circumstances.

Similar to Italy, New York City was impacted by the COVID-19 pandemic at levels not seen in other areas of the world. As of October 2020, the New York metropolitan area has recorded 250,970 COVID-19 cases with 58,580 associated hospitalizations and 19,309 confirmed deaths. In line with the current report, a 76.5% decline in ATAAD was noted in New York between March and April when compared with January and February of the same year (12.8 ± 4.6 cases/month pre-COVID-19 vs 3.0 ± 1.0 cases/month post-COVID-19, P = .007). Simultaneously, an 8- to 10-fold increase in at home deaths was observed. While one can only speculate, it is likely that these 2 findings correlate for similar reasons, namely patient apprehension and fear as well as a health care system pushed to the limits of its capacity.

This report highlights an unavoidable truth—surgical emergencies do not quarantine. When not corrected surgically, ATAAD is associated with a 60% 30-day mortality. Furthermore, delayed presentation is associated with worse outcomes, with a 1% to 2% increase in mortality per hour from symptom onset. Therefore, rapid recognition, diagnosis, and treatment is paramount. The barriers described by the patients in this report are important to address. As COVID-19 continues to have a significant impact throughout the world, it is imperative that we urgently develop strategies to maintain a safe and efficient health care network capable of providing expeditious care.