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Resuming Elective Cardiothoracic Surgery during COVID-19 Outbreak

Take home message

Mert Sentürk

What we have learned during this webinar is that it is not possible to give strict suggestions about how to resume elective surgery. This is completely understandable and normal: conditions differ not only from country to country, but also from city to city, even from center to center.
The webinar helped us focusing on what we have in “scales of the balance”: On one scale, we have – and this is the most important part – many patients, waiting since a long time to be operated, with tumors or heart failure, whose health is getting worse every day.
At the same scale we have also the financial issue, that even we, as doctors, should not ignore.
But on the other scale we have to keep in mind the constant risk of contracting and spreading COVID-19 infection. In fact, it is never (and nowhere) possible to extensively isolate covid (+) and covid (-) patients: Tests are never enough sensitive and specific. There is (and will always be) a risk of contagion, both for doctors and patients.
The webinar helped us:
1. In making “better” decisions regarding the different factors in the scales of the balance.
2. In decreasing the risks both for the patients and for the health personnel during the pre, intra-, and postoperative period.


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Summary:  EACTA webinar: Resuming Elective Cardiothoracic Surgery during COVID-19 Outbreak

Dr. Hans-Christian Zaun, Ph.D. Scientific Advisor, MULTILEARNING GROUP.

 This webinar on Resuming Elective Cardiothoracic Surgery during the COVID-19 Outbreak is hosted by Dr. Mert Senturk of Istanbul University, Istanbul, Turkey, and moderated by Dr. Laszlo Szegedi, from Brussels, Belgium and Dr. Mohamed El Tahan of Mansoura University, Egypt, and Imam Abdulrahman Bin Faisal University, Saudi Arabia.

The first speaker, Dr. Turgay Tuna of CUB Hospital ERASME, Brussels, Belgium, begins the webinar by discussing the economic impacts that COVID-19 pandemic had on hospital settings in Belgium. He begins by discussing the COVID-19 pandemic in Belgium and his institution, particularly the economic implications due to the cessation of elective surgeries. The postponement of elective surgeries resulted in considerable losses to hospital revenue, and financial resources allocated to the hospitals for staff infrastructures and supplies will not nearly be enough. He also discusses the issue of short-term absenteeism among hospital staff due to suspected COVID-19, and with the resumption of elective surgeries, increased staff and materials will be critical.

Dr. Alexander Wahba from St. Olavs University Hospital in Trondheim, Norway, continues the webinar by discussing patient assessment for returning to elective cardiac surgeries in a dedicated COVID-19 hospital. He begins by discussing the COVID-19 pandemic in Norway and at St. Olavs Hospital as well as the differences between Norway and other European Nations. Of particular note was that in Norway, the centralized management of personal protective equipment (PPE) resulted in the transfer of supplies to the hospitals where they were most needed.  Dr. Wahba states that the main obstacles with the restoration of elective surgeries will most likely include shortages of PPE and ICU capacity. However, the increased risk of COVID-19 infection will also be a factor. He addresses several crucial recommendations that include a gradual increase in elective surgeries, testing of patients and staff, reduction in the number of personnel in one place, and finally, the use of prognostic tools to better prepare for different scenarios in the future.

Dr. Alessandro Brunelli of St. James University Hospital, Leeds, UK, discusses elective thoracic surgeries in a dedicated COVID-19 hospital. After reviewing the pandemic situation in the UK, he examines several vital factors in deciding which patients should undergo elective surgeries. He presents numerous protocols, guidelines and recommendations from multiple organizations and publications on the gradual return to elective surgeries. When selecting which patients will undergo surgery, several factors must be considered. These factors include the availability of resources, alternative treatments, surgical risk, as well as the long-term prognosis. Dr. Brunelli concludes with various recommendations on how to stratify patients based on risk assessment.

Dr. Steffen Rex from the University Hospitals Leuven, Belgium, discusses the reduction of risk by preoperative assessment and optimization. He begins by explaining how the postponement of elective cardiothoracic surgeries has resulted in numerous indirect implications that may increase overall mortality. Of particular interest, Dr. Rex discusses how the pandemic has resulted in a reduction of admissions related to cardiovascular disease, even though a higher incidence of heart attacks would be expected. He explains this paradox is primarily due to the avoidance of medical care due to social distancing, fear of contracting COVID-19 as well as STEMI misdiagnosis. He then provides a roadmap for the reopening of elective surgeries, as well as prioritizing and scheduling operations. Finally, he discusses preoperative screening and assessment and gives several recommendations.

The final speaker, Dr. Fabio Guarracino, from the Azienda Ospedaliero Universitaria Pisana, Pisa, Italy, presents numerous tips and strategies for both the intraoperative and postoperative procedures to reduce the risks of contagion for both patients and hospital staff.  It is crucial to understand where these risks originate, mainly the numerous aerosol-generating procedures and lung resections. Dr. Guarracino discusses the importance of PPE, transportation and preparation of COVID-19 patients, as well as proper operating theatre organization. Dr. Guarracino concludes by stating that it is imperative that the medical community learn from their experiences during the pandemic, and particularly highlight any errors where things can be improved. Planning for the second wave, and a progressive resumption of elective surgeries is crucial.

After joining this webinar, you will better understand:

  • Impacts of long-term lockdown during the COVID-19 outbreak;
  • Considerations and consequences of returning the elective cardiac and thoracic surgery during the COVID-19 era;
  • Changing routines of the perioperative care to minimize risks for returning the elective cardiothoracic surgery.

Target audience:

Cardiac, thoracic and vascular anaesthetists and surgeons, healthcare business professionals, intensivists, perfusionists, general anaesthetists, anaesthesia certified nurses, nurses, interns, and medical students.

Chairman:Mert Senturk (Chair of EACTA Thoracic SSC, Istanul, Turkey)
Moderator: Mohamed El Tahan (Chair of the EACTA Education Committee), Mansoura, Egypt; Laszlo Szegedi, Brussels, Belgium 

  • The economic implications of COVID-19 on the healthcare system – Turgay Tuna, Brussels, Belgium
  • Returning to Elective Cardiac Surgery in a Dedicated COVID-19 Hospital: how, when, for which patients? – Alexander Wahba, Trondheim, Norway
  • Returning to Elective Thoracic Surgery in a Dedicated COVID-19 Hospital: how, when, for which patients? – Alessandro Brunelli, Leeds, United Kingdom
  • How to Reduce Risks: Preoperative Assessment and Optimization – Steffen Rex, Leuven, Belgium
  • How to Reduce Risks: Intraoperative and Postoperative Tips – Fabio Guarracino, Pisa, Italy
  • Take-Home Message – Mert Senturk, Istanbul, Turkey

In asymptomatic patients, PCR testing is still the gold standard. In regions with a high COVID prevalence, patients with a negative test result can be operated, however, PPE should be used for aerosol-generating procedures (given the risk of false-negative results). In regions with a low COVID-prevalence, negative patients can be operated without PPE. Several societies have advised against the use of antibody tests given the risk of false-positive results. Moreover, it is up to know not known whether antibodies (and which levels) are protective against a SARS-CoV2 infection. Chest CT has a role in symptomatic patients with a negative PCR test.


I do not have concerns if the obese patients have a negative test result and appropiate measures are taken to avoid infection of the patients within the hospital. In fact, even in the fiercest pandemic, hospitals seem to be a safer place than for e.g. the supermarket!


After Covid patients jump into elective surgery can be very overwhelming, not to mention that we do not know how second wave will look like. If we look at the absenteeism numbers, we see that the short-term absenteeism observed during the caregivers mobilization is becoming once more a long-term absenteeism in our hospital. It is probably polyfactorial but tiredness is certainly one of them. We did our best to readapt elective surgery step by step (25%->50%->75%) to help them recover and use their supplementary hours. Fear of the patients to go to hospitals to be treated in the early phases is also vanishing and it will be a struggle to absorb everything since some wards will remain closed because of a deficit in human resources.


At first, two hospitals were designated as reference hospitals but it changed quickly with th growing number of Covid-19 patients and all general and university hospitals took care of them. As I showed, the impacts will be consequent as a clear deficit in day-admissions, interventions is observed for march, april and may. You can estimate it as a reduction of 20% of the yearly income, without taking into account the costs for all the modifications related to the infrastructural adaptations, the materials, etc. We received 1 million in funds that was used essentially for the infrastructure (multiple wards corresponding in total to nearly 300 Covid adapted beds and 69 ICU beds (44 Covid, the rest for ICU surgical and medical non-Covid patients). We concentrated all ventilators for the ICU and had in fact a reserve of 99). Many others received more consequent funds (till 4 million euros) and used them to buy ventilators and to modify their wards to adapt it as ICU wards. The government at one point centralized the distribution of gowns, masks and anesthetic agents, creating more difficulties because the repartition keys were unadapted to the reality of the situation.


We prioritized essentially all oncological interventions. Our neuroradiologists selected the more at risk patients needing endovascular interventions, same with our vascular surgeons, but we observed a frank diminution of thrombectomies during the pandemic, as well as a net reduction in emergency visits, proof that the fear effet of the pandemic predominated at the risk of having persistent lesions.


It is very difficult at this stage comment on the mortality rates in different Countries as different Countries may have different ways to record deaths as linked to COVID-19. The high death toll in UK may be attributed to a different policy or timing of implementing social distancing measures decided by the Government compared to other Countries and to lack of testing in the initila phase. In my opinion the problem of death rate is a much more complexmatter than simply counting the deaths directly due to the virus. The true effects of this pandemics on the different Countries will have to take account of the many indirect deaths caused by the undertreatment or underdiagnosis of other acute or chronic illnesses caused by the lock down measures compounded by the impeding financial crisis that will affect in a different amount different Countries. We need to wait months or years to know the real cost of COVID-19.

In my opinion PPE should still be used even in tested negative patients especially for aerosol-generating procedure like thoracic surgery. This is our practice in Leeds at the moment. All staff in theatre wear full PPE for all cases (no matter if tested negative). The current risk of contracting the virus in our Hospital is thought to be less than 1% and we did a good job in segregating the COVID-19 patients in a dedicated aerea and keep elective surgical wards and teatre COVID-free. Still given the false negative rate of the current testing we think all staff in theatre should wear full PPE for all cases.

Although a thorough analysis is difficult during the pandemic there are indications for an indreased mortality as a result of reduced incidence of registered MI admissions in hospital. There is a study published in EHJ from Italy confirming this (Eur Heart J. 2020 Jun 7;41(22):2083-2088. doi: 10.1093/eurheartj/ehaa409.Reduction of Hospitalizations for Myocardial Infarction in Italy in the COVID-19 Era by De Rosa et al.)

Lung separation can be attempted witout FOB and checheck with clinical semeiotics. However, should FOB be needed, like in difficult blind lung separation or need for bronchial blocker, this manouver should be performed by fully protected anaesthesia staff (wearing full PPE), with the patient under apnoea.

NIV and HFNO are considered AGP, as such avoiding their use has been recommended. However, should their use be considered clinically strongly recommended, the application should occur in a negative pressure environment by fully protected (wearing full PPE) medical and nurse staff.

ECMO was used in a very minority of patients. This was due to the very high pressure put on the ICU by the very large number of patients, and to the different clinical presentation of the SARS-CoV-2 respiratory disease if compared to standard ARDS.

In a preoperatively Covid 19 negative patient, PCR swab test is needed. In a preoperatively Covid 19 positive patient, two consecutive negative PCR test in 24 h are requested.

A transport ventilator is safer. Viral filters should be connected to the ventilatory circuit.

Event Details
  • Start Date
    June 8, 2020 5:00 pm
  • End Date
    June 8, 2020 7:00 pm
  • Status
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