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Review
. 2020 Jul 7;9(13):e017042.
doi: 10.1161/JAHA.120.017042. Epub 2020 May 16.

Cardiac Surgery During the Coronavirus Disease 2019 Pandemic: Perioperative Considerations and Triage Recommendations

Affiliations
Review

Cardiac Surgery During the Coronavirus Disease 2019 Pandemic: Perioperative Considerations and Triage Recommendations

Vivek Patel et al. J Am Heart Assoc. .

Abstract

The coronavirus disease 2019 pandemic, caused by severe acute respiratory syndrome coronavirus-2, represents the third human affliction attributed to the highly pathogenic coronavirus in the current century. Because of its highly contagious nature and unprecedented global spread, its aggressive clinical presentation, and the lack of effective treatment, severe acute respiratory syndrome coronavirus-2 infection is causing the loss of thousands of lives and imparting unparalleled strain on healthcare systems around the world. In the current report, we discuss perioperative considerations for patients undergoing cardiac surgery and provide clinicians with recommendations to effectively triage and plan these procedures during the coronavirus disease 2019 outbreak. This will help reduce the risk of exposure to patients and healthcare workers and allocate resources appropriately to those in greatest need. We include an algorithm for preoperative testing for coronavirus disease 2019, personal protective equipment recommendations, and a classification system to categorize and prioritize common cardiac surgery procedures.

Keywords: COVID‐19; SARS‐CoV‐2; cardiac; coronary artery bypass grafting; surgery; virus.

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Figures

Figure 1
Figure 1. Perioperative severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) testing strategy for patients without acute infection undergoing cardiac surgery.
*This testing algorithm provides guidance on personal protective equipment (PPE). The decision to perform a case is primarily dependent on the surgical indication (tier 1, 2 or 3 [Table 2]) and not coronavirus disease 2019 (COVID‐19) testing. However, knowing the COVID‐19 test results may help with guidance for surgical timing, patient counseling on postoperative complications, and allocation of hospital resources. If resources to test all preoperative patients are available, we recommend universal testing for the reasons mentioned above. The test should be performed as close to surgery as possible. Time permitting, tier 3 patients may also be tested. Stratification by pretest probability is useful in limited‐resource settings. Local/regional disease prevalence may serve as a surrogate for the pretest probability. High pretest probability: local community/facility prevalence of >20% to 50%; intermediate pretest probability: for patients who are not considered to have high pretest probability or low pretest probability; low pretest probability: no documented local community‐based transmission, asymptomatic patient, and the patient and patient's close contacts have not traveled within 14 days.
Figure 2
Figure 2. The relationship of positive and negative predictive value to prevalence.
This schematic illustrates the relationship between positive predictive value (PPV), upper left, and negative predictive value (NPV), lower left, to prevalence. Varying sensitivities for these assays are also illustrated (red, 90%; blue, 80%; green, 70%; purple, 60%; all groups use specificity of 95%). In a low‐prevalence setting, the PPV is low. In high‐prevalence settings, the NPV falls below 80% to 90%. In intermediate‐prevalence settings, the PPV and NPV are both high. The diagnostic test may, therefore, be the most valuable for patients with intermediate pretest probability. Each facility should review its local thresholds for PPV and NPV, and review its facility's diagnostic assay. The schematic was created by A.C.3

References

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