Charting a Safe and Expeditious Course Back to Elective Cardiac Surgery During the COVID-19 Pandemic

“The compass of accurate knowledge directs the shortest, safest, cheapest course to any destination.”

– Claude C. Hopkins

The novel coronavirus disease 2019 (COVID-19) pandemic has swept across the United States, leaving a wake of unprecedented disruption. At the front lines, hospitals have swiftly enacted large-scale structural and organizational changes in order to meet the unique challenges of the pandemic. Based on the recommendations of the Centers for Medicare and Medicaid Services (CMS), ¹ most hospitals across the United States have significantly curtailed all non-emergent procedures in an effort to conserve resources for a potential surge in severe COVID-19 infections. Consequently, cardiac surgeons have found themselves in uncharted waters due to indefinite cancellation of elective cardiac surgery. At the same time, while some patients with surgical-level cardiovascular disease have been left unable to access definitive treatment, others are avoiding the hospital altogether for fear of infection. ^{2 -4} What has become clear amidst the flux and uncertainty of the pandemic is that we must find a way to remain available to our patients by charting a safe and expeditious path toward resumption of elective cardiac surgery.

At the urging of the federal government, ⁵ hospitals across the nation have slowly begun to plan for phased reopening of elective surgery. Although guidance statements such as those from the American College of Surgeons exist, ⁶ the unique position of cardiac surgery within the spectrum of all elective surgery warrants specialty-specific considerations. Our patients are particularly tenuous and face an elevated risk of morbidity and mortality while waiting for surgery. Escalation of a case from elective to urgent based on clinical deterioration is not uncommon in our field. Elective cardiac surgery also requires substantially more resources (e.g., mechanical ventilation, blood products, inotropic medications, intensive care beds) compared to many of the other surgical subspecialties. Finally, the deleterious effects of cardiopulmonary bypass on the lungs may render these patients especially vulnerable to severe COVID-19 infection; however, evidence on this subject is purely speculative. Taken together, these unique challenges underscore the need for a specialty-specific roadmap. In the context of limited evidence at this time, we provide initial considerations for programs embarking on paths toward phased reopening of elective cardiac surgery.

Phase 1—Preparation

A central requirement of most guidance statements regarding the resumption of elective surgery is confirmation of a sustained decrease in the rate of new COVID-19 cases in a given area for at least 14 days. It would, therefore, be remiss not to emphasize the critical importance of testing at this point. In hindsight, what will likely be recognized as the single greatest flaw in our national response to the COVID-19 pandemic was our inability to provide sufficient testing. Our limitations on this front have contributed to profound variation in estimates regarding the peak and duration of COVID-19 surge based on epidemiologic predictive models. ^{7 -10} While speculating on this data as it applies to a given geographic region may be a Sisyphean task, hospitals may ultimately find greater return on investment by developing a robust internal infrastructure for real-time data collection and analysis in order to triangulate between regional COVID-19 burden, hospital resource capacity, and backlog of elective cases. With such infrastructure in place, hospitals will be positioned to assess continued safety and make proactive rather than reactive adjustments as they progress through staged reopening of elective cardiac surgery.

In order to safely and sustainably resume elective cardiac surgery, programs must first ensure that their hospitals have the requisite resources and personnel. Programs will be tasked with the challenge of gradually increasing capacity to address the mounting backlog of time-sensitive cases in systems that may have been significantly depleted of resources due to the pandemic. Therefore, programs that have experienced profound disruption should not feel compelled to resume elective cardiac surgery immediately. Hospitals must confirm they can provide a sufficient number of adequately trained personnel and appropriate staffing ratios for all perioperative phases. It is also imperative for hospitals to have an adequate supply of personal protective equipment for their staff. Protecting the members of the surgical and perioperative teams, as well as the patients, must be a top priority throughout this process. This will require concerted attention to all phases of the personal protective equipment supply chain, including regional and national supply, daily burn rate, as well as policies and procedures to minimize waste.

Phase 2—Outpatient Diagnostic Testing

With the requisite infrastructure in place and in compliance with evolving local public health policy, programs may embark on phased reopening of elective cases. The first phase should center around reestablishing and optimizing the preoperative workup process. This phase can be initiated with minimal strain on inpatient hospital resources while additional perioperative process planning is underway. Many patients who were originally scheduled for surgery but were delayed may require repeat laboratory or imaging tests, history and physical exam, and/or a renewed consent. Protocols will need to be established to determine which patients should be seen again in the clinic by a surgeon versus those who could be seen in a general preoperative clinic or via telemedicine. Regardless, efforts should be made to accomplish as much of the preoperative workup in as few visits as possible in order to minimize the risk of potential transmission. In certain cases, this will require considerable coordination, especially for patients who require invasive tests such as cardiac catheterization or for patients who require staged tests such as those with renal insufficiency who require multiple intravenous contrast administrations.

Cardiac surgery programs should aim to create individualized perioperative COVID-19 testing algorithms in order to maximize the efficiency of available testing capacity. At a minimum, all patients scheduled for elective cardiac surgery should be tested for COVID-19 within 72 hours prior to surgery as part of standard preoperative workup. Careful consideration should be directed toward the management of patients who test positive for COVID-19 during the preoperative phase. Preliminary retrospective data suggest unacceptable morbidity and mortality in patients who underwent elective noncardiac surgical procedures and developed COVID-19 infection postoperatively. ^11,12 Therefore, patients scheduled for elective surgery who test positive should have their surgery canceled if safe to do so and be sent home to self-isolate with instructions to return to the hospital for further evaluation following recovery. A similar approach may be appropriate for patients who test negative but have significant exposure history, given the high false-negative rates associated with current polymerase chain reaction (PCR) tests. ¹³ If feasible, hospitals could consider establishing a dedicated multidisciplinary team of infectious disease doctors, cardiologists, cardiac surgeons, and anesthesiologists charged with surgical planning and close monitoring of these patients (both for their COVID-19 status as well as their underlying cardiovascular condition). As we deepen our understanding of COVID-19 infection, we may need to adapt these algorithms and consider the role of repeat PCR testing, serological testing, and serial imaging in determining the optimal timing for elective cardiac surgery in a patient who has previously tested positive for COVID-19.

In addition, hospitals will need to establish an appropriate policy for testing of health-care workers. Initial testing in the United States has been limited to symptomatic individuals; however, there is inadequate evidence to support this strategy. In fact, a recent study showed that approximately 44% of infections are transmitted during the primary patient’s presymptomatic phase. ¹⁴ This is highly concerning given the sheer number of individuals involved in the care of cardiac surgery patients. There are significant limitations to the current antibody assay technology including assay-to-assay variability along with limitations to our understanding of the implications of a positive titer. Nevertheless, serology may prove to be especially useful in this context. For example, if a positive titer is found to confer immunity to subsequent infections, hospitals may be able to use exposure history and serostatus to strategically staff units and operating rooms in a manner that bolsters infection control. Unfortunately, no testing algorithm is infallible. Given the high false-negative rates associated with current PCR tests, ¹³ hospitals may also need to devise a system for contact tracing within the hospital in order to prevent localized outbreaks.

Phase 3—Elective Surgery

Once a thorough mechanism for identification and management of patients who tested positive for COVID-19 during the preoperative workup is in place, programs may begin to resume elective surgery. Given the variation in time-sensitivity of cases between surgical subspecialties, a governance committee including administrators, surgeons, anesthesiologists, and intensivists could be established to create a prioritization policy for elective cases. This committee could also establish a predetermined capacity goal for resources dedicated to the operating rooms to accommodate a potential surge of patients with COVID-19 infection without compromising the safety of postoperative patients.

Several valuable guidance statements for the triage of time-sensitive elective cases ^15,16 along with a resource prediction instrument for cardiac surgery from the Society of Thoracic Surgeons ¹⁷ have been made available recently. Other programs have developed similarly useful models for resource allocation. For example, the Texas Medical Center has created an online dashboard that allows hospitals to monitor regional COVID-19 burden, personal protective equipment needs, and ventilator and intensive care unit bed capacity. ¹⁸ In addition, a multicenter team developed a simple mathematical model to estimate the time required to clear the backlog of elective cardiac surgery cases based on variable levels of postsurge surgical volume. ¹⁹ These can serve as preliminary support tools as hospitals develop their own individualized prediction models. These initiatives also highlight the value of regional centralization of data. Similar platforms to share data and best practices between programs will be invaluable to our collective progress. Hospitals may need to accept a shift in paradigm to one where collaboration will rule over competition when it comes to providing their communities with access to safe elective cardiac surgery during the COVID-19 pandemic.

At this stage, hospitals should also incorporate strategies to mitigate the risk of postoperative nosocomial infection, especially as they take on more complex cases that require prolonged length of stay. For example, given the curtailed surgical volume and decreased census at most hospitals, it may be possible to bypass the pre- and postoperative anesthesia care units altogether in order to accomplish this aim. In addition, routine postoperative testing and procedures can be ordered more judiciously and medication administration can be clustered when feasible.

Programs should also develop algorithms for the diagnosis and management of postoperative patients with suspected COVID-19 infection. In a retrospective series of patients who underwent elective thoracic surgery and developed COVID-19 infection postoperatively, ¹² the authors highlight some of the diagnostic challenges in the postoperative setting and advocate for liberal use of computed tomography scans at the onset of symptoms while awaiting confirmatory testing. In line with these recommendations, hospitals may consider a low threshold of suspicion for COVID-19 infection in patients after cardiac surgery, with early and serial testing at as many time points as necessary.

Programs should also dedicate ample consideration to the importance of visitation policy in our field. Given the gravity of our surgeries, many patients wish to have their families present during their recovery. Unfortunately, allowing unrestricted visitation potentially poses risks to our vulnerable patient population and undermines the value of preoperative testing to identify COVID-19 infection. Accordingly, most hospitals have adopted strict visitation policies, and will likely need to find creative solutions such as tablets with video chat technology or accommodations for a single family member to stay with the patient in the hospital postoperatively.

Phase 4—Business as Usual

In order to resume business as usual, we will need to ensure either (1) negligible transmission in the community or (2) negligible risk of severe infection in postoperative patients. Meeting the first condition in the absence of a safe and effective vaccine is unlikely. While hundreds of vaccine candidates are in development, ²⁰ we must consider the fact that the timeline to bring an efficacious vaccine to market is unknown, but possibly on the order of years if it were to mirror historical timelines. On the other hand, although new potential treatments emerge almost daily, none are currently supported by high levels of evidence. It is imperative that we as a specialty lead by example and practice patience and promote evidence-based medicine. This is not the time to peddle mechanistically intriguing potential treatments or needlessly wasteful, ineffective practices, but rather the time to demand rigorous studies rooted in safety and efficacy.

As difficult as it may be, we will need to temper our eagerness and momentum and steel ourselves to the reality that in contrast to the previous phases, which may have been separated by weeks or months, progression to this final phase could last much longer. In the meantime, embracing adaptive strategies to provide safe cardiac surgery in this new landscape will likely prove to be a more fruitful venture than attempting to restore our old sense of normal.

Conclusions

The path toward phased reopening of elective cardiac surgery will require patience, humility, and frequent recalibration in response to emerging data. Programs should implement dynamic COVID-19 testing protocols, examine capacity, and create prioritization policies in order to ensure safety and sustainability. At all phases during the pandemic, we must be transparent with our patients and maintain the highest standard of surgical care all the while maintaining preparedness for a potential surge in COVID-19 cases. In the face of this challenge, it is worth remembering that as a specialty, we are tasked with similarly high-stakes decisions daily when we counsel our patients, carefully balancing the risks of surgery against the risks of untreated disease. We are therefore uniquely qualified to captain this ship and chart a safe and expeditious course back to providing elective cardiac surgery for our patients.