The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: Insights and clinical strategies from a center at the epicenter

Abstract

Background: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training.

Methods: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process.

Results: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future.

Conclusions: We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.

Keywords: COVID-19; New York; cardiac surgery; pandemic; reorganization.

Decision-making strategy for cardiac surgery patients in the COVID-19 pandemic.

Figure 1

Representative photograph of an ORICU: This is an operating room that has been modified to accommodate up to 4 ventilated patients with COVID-19, each with a separate ventilator, gas lines, and other equipment.

Figure 2

The anticipated resource use depends on the stage of the pandemic at a given health care system. Three potential scenarios can exist: system A: COVID-19 cases exceed resources, causing a complete cessation of surgery throughout the peak and affects the late phase, system B: COVID-19 cases cause major disruption only in the peak phase, and system C: COVID-19 cases stay below maximum resource capacity, allowing elective cases to proceed. Note there is a predicted bump in cases within the late phase as distancing measures are relaxed.

Figure 3

A, Decision-making strategy for surgical planning based on pandemic phase, given operative risks and expected life years gained, resource use, and resource limitations. In this figure, 3 phases of pandemic can be plotted with resource expenditure on the vertical axis (blue line: resources available; orange line: resource use), and operative risk and expected survival benefit on the horizontal axis. The intersection of the orange and blue resource lines represents the maximum case threshold for a health care system at a given time. This graph thus incorporates the changing level of resources at different stages of the pandemic, as illustrated by a sample case of an 80-year-old patient with CKD requiring AVR/CABG. In B, during the peak of the pandemic, this operation is not justified; in C, during later stages of the pandemic, this operation is justified. CKD, Chronic kidney disease; AVR, aortic valve replacement; CABG, coronary artery bypass grafting.