By Dr. Farooq Ahmad Ganie
A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has been declared a Public Health Emergency by WHO since January 2020. The rapid, exponential, increase in cases makes prevention and control of coronavirus disease (COVID-19) extremely critical. Although clinical manifestations of COVID-19 are mainly respiratory, the patients may develop severe cardiovascular damage which may lead to fatal outcome. The impact of COVID-19 on cardiac surgery is immense. Cardiac surgery practice might not be on the frontline of COVID-19 patient care. However, the pandemic affects cardiac surgery units in important ways like limited intensive care unit (ICU) beds and ventilation sites, necessity to postpone elective and/or complex cardiac surgeries, shortage of health care workers, sick health care staff, restrictions in clinical cardio-surgical meetings ( limiting the number of attendees in cardio-surgical meetings), patients developing COVID-19 after cardiac surgery, patients with COVID-19 needing urgent cardiac operations, and cancelation of training and education, professional conferences, exams, courses. Due to all these factors the cardiac surgery has been badly touched. As cardiac surgeons, we have a responsibility to ensure that evidence-based, essential cardiac operations are provided to the general public in the present health care crisis time but at the same time the wider burden of those procedures on the healthcare system and health care workers must be minimized of COVID-19 to do away with the crisis.
COVID-19 puts health services and health care providers under immense mental and physical pressure. The decision on whether or not to perform cardiac surgery is not always easy with continued escalation of disease burden. The decisions on cardiac surgeries became more difficult with many dilemmas— should we operate in this escalating phase only on younger, low risk patients or only extreme emergencies. It is very important when these decisions are made, both the decision process and the decision made has to be documented and should withstand with medico legal aspect too. At the same time, the surgeon while taking the decision must consider the risk of exposing these patients to a possible COVID-19 infection during hospitalization and/or exposing himself and other health care workers to the infection. We must bear in mind that most patients with COVID-19 have mild or no symptoms and therefore, it may be difficult to identify such patients. One must realize that cardiac surgery units have a responsibility to the patient, in a particular state. Therefore, during these difficult times, patients with elective cardiac procedures may be best managed by delaying their care until a few months or year. This may be in the patient`s best interest, and in the interest of health care providers. It has been proved that patients with acute cardiac pathologies who are infected with SARS-CoV-2 often have a poor prognosis. Therefore, developing COVID-19 after cardiac surgery might be associated with a high mortality.
But there is a certain group of patients like those with acute coronary syndrome, in case of severe coronary artery disease (e.g. severe left main trunk stenosis, severe triple vessel disease with high SYNTAX score) who are not eligible for conservative or interventional treatment may be operated on. This may be true also for younger patients with symptomatic severe aortic valve stenosis, left-sided endocarditis with a severe valve defect and/or large mobile vegetation, large ascending aortic aneurysm, acute type A aortic dissection and acute heart failure due to severe coronary artery or valvular heart disease. Under such circumstances decisions should be made depending on available resources and supported by an ethical and legal framework. What should be done and what should be avoided remains still unanswered. How can we protect the patient and health care workers? It is crucial to provide a thoughtful decision making process on whether or not a cardiac surgery should be performed. Decisions made today may be different from those made only a few days later under these rapidly changing circumstances. One must weigh the risk of delaying surgical care with the risk of exposing the patient to COVID-19.
The COVID‐19 pandemic has affected health care system with uncertainty of decisions. Massive and large scale research is need of hour to understand to develop preventive treatments, and establish management protocols in cardiac surgery patients through such period.
(The Author Is Assistant Professor Department Of Cardiovascular And Thoracic Surgery SKIMS Soura)
