Resuming Elective Cardiothoracic Surgery during COVID-19 Outbreak

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.