Impact of COVID-19 on Coronary Artery Surgery: Hard lessons
learned
Author: Luis Alberto O. Dallan1; Luiz Augusto F.
Lisboa1; Luis Roberto P. Dallan1;
Fabio B. Jatene1.
1 Department of Cardiovascular Surgery, Heart
Institute from University of São Paulo Medical School (InCor), São
Paulo, São Paulo, Brazil.
Corresponding author: Luis Alberto O. Dallan, Dr. Enéas de
Carvalho Aguiar, 44, Postal Code:05403-900. Pinheiros, São Paulo, SP –
Brazil. Phone: +55 (11) 2661-5014.
E-mail: dcidallan@incor.usp.br.
Since March 11th, 2020 when coronavirus disease 2019 (COVID-19) was
declared a pandemia, hospitals had to be adapted quickly to increase the
assistance capacity for a large part of the population that needed
hospitalization for severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection (1,2). Major disruptions on routine hospital
services have occurred, with health professionals needed to assume
functions beyond their usual routines and beds were adapted for
intensive care due to the increased demand in the treatment of severe
acute respiratory failure. Cardiovascular surgery was particularly
affected by the coronavirus outbreak, since most of the elective
surgeries were canceled and ICU beds, normally dedicated to the
postoperative period of cardiac surgery, were transferred to patients
with COVID-19 (3-5).
In this context, Kalil and Col.(6) examine the impact of the Covid-19
pandemic in the number of procedures and death rate of CABG performed in
2020 in Brazil. They analyzed patients undergoing CABG in the public
health system between 2008 and 2020. The data were collected from
DATASUS, the data processing system of the Brazilian Ministry of Health,
which collects information from every patient who needs in-hospital care
and was admitted to a public hospital. Patients operated on the private
system were not captured in the database and were excluded from the
analysis. The results showed that in 2020, during the pandemic period,
there was an average reduction of 25% in the number of CABG performed
in Brazil, with the majority of procedures (75%) being performed in the
south and southeast regions of the country. Regarding postoperative
mortality, they observed an opposite effect with an increase in
mortality from 5.6% to 6.3% during this pandemic period (6).
This study has some limitations due to results extracted from an
administrative database, good for epidemiological analysis such as
gender, age, number and type of surgeries performed. Considering the
reduction in surgical volume during the pandemic period, surgical status
was analyzed altogether (whether elective, or urgent or emergency CABG),
expressing a general view of the situation.
Brazil was the epicenter of the coronavirus outbreak in Latin America
and other publications from Brazil showed different and more detailed
results in relation to the pandemic period (7,8). One by Omar et al. (7)
who used data from the São Paulo Registry of Cardiovascular Surgery
(REPLICCAR), a multicenter registry, showed a 60% reduction in surgical
CABG volume during COVID-19 pandemic. Regarding mortality, CABG
surgeries had a 2.8-fold increased mortality risk (CI95%,1-7.6,
P=0.041), patients who evolved with COVID-19 had a 11-fold increased
mortality risk (CI95%, 2.2-54.9, P<0.003), rates of
morbidities and readmission to the intensive care unit. (7), compared to
2019.
In our own series at the Heart Institute University of Sao Paulo Medical
School - Brazil, we observed a 65.8% reduction in cardiac surgery
volume in 2020, during the pandemic period, and 2/3 of these were urgent
or emergency procedures. Regarding the CABG in-hospital mortality, there
was increased from 1.2% (2019) to 3.0% (2020) among elective
procedures and from 4.5% (2019) para 18.2% (2020) among urgent or
emergency procedures. Patients who had postoperative COVID-19, the
in-hospital mortality rate was significantly higher (38.5%).
Other publications reported a reduction in surgical volume of more than
70% during the peak disruption due to COVID-19 (9,10). Salenger et al.
(11) reported that the volume of cardiac surgery fell to 54% of
baseline after the restrictions were implemented and they also estimated
a necessity of 2.5 times increase in numbers of procedures in
post-COVID-19 era to restore balance to elective surgeries waiting
lists. In the COVIDSurg collaborative, in a multi centric cohort of
surgeries performed in 24 countries (235 hospitals), found that 75% of
the procedures from 1 January and 31 March 2020, were non-elective and
the mortality was 24%. Their cohort included 50 patients who underwent
cardiac surgery and 30-day mortality was 34%, among the patients who
had perioperative SARS-CoV-2 infection (12). Clinical studies have shown
that in addition to severe acute respiratory distress syndrome, the
coronavirus-2 infection also affects micro-circulation, has
prothrombotic state and can cause myocardial injury, even in patients
without coronary artery disease (13-14). This may be one of the reasons
for the high mortality among patients who undergo surgery and present
COVID-19 in the perioperative period, particularly in CABG surgery,
where there is also a higher incidence of elderly, hypertensive and
diabetic patients.
While the COVID-19 pandemic continues to increase globally, measures to
control SARS-CoV-2 infection and patient safety need to be established
to maintain cardiovascular surgery, even if in small numbers. The
consequences of delayed recognition of a patient with COVID-19 are
significant. Protocols for triage, early diagnosis, isolation in
specific areas and treatment of patients with COVID-19 with
cardiovascular complications should be developed to minimize the risk of
in-hospital transmission and greater safety for hospitalized patients
without COVID-19 and healthcare professionals (15,16).
A large number of operations were canceled or postponed due to
interruptions caused by COVID-19. Coincidentally, our institution have
reported an increased number of mechanical complications, that maybe
related to decreased number of patients seeking for medical assistance
(17).
Studies conducted in the first months of the pandemic showed that if
countries increased their normal surgical volume by 20%, it would take
an average of 45 weeks to balance the backlog of operations resulting
from the interruption of COVID-19 (18). Patients awaiting elective
cardiac surgery need to be proactively managed, reprioritizing those
with high-risk anatomy or whose clinical status is deteriorating. In
this regard, governments must mitigate this heavy burden on patients by
developing recovery plans and implementing strategies to safely restore
surgical activity as soon as possible.