|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
Covid-19 and cardiothoracic surgery
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine; Department of Surgery, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas, USA
|Date of Web Publication||24-Dec-2020|
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine; Department of Surgery, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mattox KL. Covid-19 and cardiothoracic surgery. J Cardiothorac Trauma 2020;5:1-5
Since February 2020, there have been over 60 million-confirmed cases of COVID-19 caused by a “novel” coronavirus first discovered and described in Wuhan, China. This has resulted in over a million deaths worldwide over 230,000 deaths in the United States. In Texas, there have been JUST OVER a million confirmed COVID-19 cases and over 20,000 deaths. It appears this virus, like other flu viruses, continues to mutate, with the most current strain (in the United States) being more contagious, but less virulent in producing severe acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admissions, and deaths.
Regardless of the level of virulence, viruses that affect organs in the chest create challenges for the cardiothoracic surgeon, whether as the patient's primary physician, a consultant, or member of a clinic or hospital staff. These interfaces and challenges fall into several areas-personal protection and risks, patient care, specific organ impact, government policies/interventions, clinic, and hospital policies, regional rumors and dogma, emotional impact, economic impact, and specific cardiothoracic procedures.
| Cardiothoracic Surgery Considerations During the COVID-19 Pandemic|| |
Personal protection equipment
ALL physicians must be vigilant to protect their patients, team, associates, families, and themselves from infection. Surgeons regularly wear personal protection equipment (PPE) in the operating room and understand the function and utility of barriers, types of materials in barriers, and specialized kinds of PPE, whether scrub suits, shoe, head, and facial hair covering, or operating room gowns. Surgeons also understand the importance of isolation rooms, air exchanges, and temperature/humidity control. Most surgeons are familiar with types of hand and body washes, be it for the patient, surgeon, nurses, family, or visitors. They are aware of the controversies concerning prep solutions and use of devices, such as ultraviolet light, to aid in ridding surfaces of bacteria or viruses. Of course, surgeons are also aware of the debates regarding regular gowns, masks, gloves, and head coverings, as opposed to use specialized air handling hoods such as powered air purifying respirator (PAPR) and Tanjore air purifying respirator (TAPR) equipment. The use of PPE is certainly justifiable; however, debates surrounding specifics of what, when and where are ongoing. Evidence-based data should guide decisions on use of PPE's, but the data are still in a state of flux. It falls to physicians to err on the side of hyper-caution, so the use of the best available PPE is advised for all high-risk procedures performed in COVID positive patients or on patients whose COVID-19 status is unknown.
Surgical departments should facilitate staggered rostering, remote meeting attendance, and self-isolation of symptomatic staff.
Economic impact on practice
Most city, county, and state leaders, during a COVID-19 surge, will attempt to reduce social interaction and conserve hospital beds so they are available for COVID patient admissions. One mechanism employed has been closing hospital operating rooms to “elective” surgery. Depending on the incidence of “emergency cardiothoracic surgery,” an individual surgeon can claim and prove a 75% or greater decrease in practice, consultations, office/clinic visits, and operations. This, obviously, has (and will continue to have) tremendous negative economic impact on that surgeon and all members and employees of the practice, as well as the vendors that serve this practice.
Specific organ impact, (cardiothoracic)
Almost every organ in the chest can be acutely affected by COVID-19 infections.
COVID-19 is a respiratory virus. The upper respiratory tree and the lungs are the most common sites of infection. Lung related issues, including pneumonia, aspiration, ARDS pulmonary hypertension, pulmonary embolism, colloid deposits, lipid infiltration, and others, have occurred. Surgeons are often involved in either managing such patients or inserting tubes, performing biopsies, and/or other necessary procedures.
Trachea and bronchus
The airways also are often involved with infection, either primary or secondary to COVID-19. The computed tomography (CT) surgeon is frequently consulted to evaluate the trachea, bronchi, and esophagus through bronchoscopy and esophagoscopy and MUST be mindful to have optimal appropriate PPE for all members of the endoscopy team. Debate continues on exactly what the ideal PPE is for these procedures, and even the more complex PPE devices, such as PAPRs, might pose additional risks during donning and removal.
The heart is directly and indirectly affected by distant disease. A patient with a preexisting cardiac condition is more susceptible to cardiac complications, should ARDS, or pulmonary hypertension develop. A patient with preexisting coronary insufficiency is more susceptible to any degree of hypoxemia. Various electrolyte abnormalities secondary to COVID-19 can and do produce cardiac arrhythmias that might result in cardiac arrest or necessitate pacemaker insertion. For COVID-19 patients, physicians must consider, well in advance, maximum protection and how external cardiac massage is to be administered while accomplishing minimal infection exposure to the team.
Thoracic great vessels
Aortitis has been described in patients with systemic viral infections, although it has not been described in the thoracic great vessels. Injury to the thoracic great vessels can be iatrogenically produced during insertion of lines for extracorporeal membrane oxygenation (ECMO) devices, and when occurring, requires repair by a cardiothoracic surgeon.
Long-term impact on thoracic organs is a consideration for thoracic physicians, although the exact nature of such long-term complications has not yet been described.
COVID-19 patients often need procedures performed, either as an aid to therapy by an intensivist or directly on a diseased organ. Cardiothoracic surgeons, especially if they also provide critical care services to hospitalized patients, are very often involved in the care of COVID-19 patients who have not undergone operation. At this point in the pandemic, all patients seen in the emergency room and admitted to the hospital are considered COVID positive until appropriate exam and/or tests prove otherwise.
Cardiopulmonary resuscitation (CPR) might be required for a COVID-positive patient in any hospital location, from the ER to the ward on the floor. For hospitalized patients, status of their COVID-19 test is usually known, but urgent and emergency patient are often “persons under investigation” (PUI) status, in which case the cardiothoracic surgeon must assume the patient is COVID-19 positive if CPR is required. Since upper airway nebulization occurs during CPR, appropriate precautions for physician and team must be taken.
During intubation, often part of a resuscitation attempt or in combating ARDS, nebulization does occur, and appropriate PPE is indicated – again, whether patient is COVID positive or PUI.
Tube thoracostomy is one of the most common operations a cardiothoracic surgeon will be asked to perform on a COVID-19 patient. The surgeon must take maximum PPE precautions. Inserting a relatively small, pigtail type percutaneous tube into the chest will lessen the risk and decrease the complexity of the procedure.
The cardiothoracic surgeon may be called on to insert central venous lines, including lines for dialysis, in COVID-19 positive patients. Ultrasound guidance to aid in insertion is advised, thus decreasing the potential for complications.
Extracorporeal membrane oxygenation line insertion
Depending on the institution, insertion of lines for ECMO might be a consultation request. The mortality rate for a COVID-19 patient placed on ECMO is very high. The best results from ECMO in ARDS patients from any cause occur in institutions that have an established ECMO program. All members of the team in the room at the time of line insertion should have maximum PPE protection. All pathology and blood banking services have emphasized that COVID-19 is not transmitted through blood from a COVID-19 patient with an active infection.
Decortication for fibrothorax and a trapped lung have not yet been reported following COVID-19. With chronic and long-term infections of the lungs, such as with tuberculosis and other infections, it is not unusual that various pleural conditions develop on the pleural surfaces. It is anticipated that such will occur in the future.
Cardiac valve/coronary artery surgery
Already, during this 1st year after COVID-19's appearance, cardiothoracic surgeons have been asked to evaluate and consider coronary artery bypass surgery, valvuloplasty, or valve replacement in patients with heart failure. Such has been requested for both actively infected patients and for those who have recovered and are several months post hospitalization. In general, surgeons have hesitated to operate on the heart during the acute phase of COVID-19 infections.
Cardiothoracic complications (clinical and “other”)
Early and acute
Early patients with COVID-19 might develop:
Right heart failure
- Fluid overload
- Cardiac arrhythmias
- Cardiac Arrest
- Pulmonary Fibrosis
- Aspiration Pneumonia.
Long-term complications are not yet known. However, one might anticipate long-term cardiothoracic complications of:
- Pulmonary fibrosis
- Heart failure
- Lung pathology requiring biopsy or resection
- Vascular deposits.
- Delayed start times for first case in the operating room
- Increased OR turn over time resulting in decreased total of cases that can be done
- Decreased number and use of ICU Beds
- Loss of an economic margin for the hospital and surgeons
- COVID-19 occurring in colleagues, friends, and family
- Loss of one-to-one interactions; replacing with virtual/“Zoom” meetings.
The emotional burden and impact of COVID-19 on ALL medical personnel, including the CT surgeon in the hospital and in the heat of the therapeutic challenges is significant and additive over time. The constant burden of long work hours coupled with the uncertainty, and fear of potential infection for self, team, and family have continued to build over time. As a result, the incidence of stress and interpersonal violence is markedly increased, and is seen in both the general population, as well as physicians and health care workers, in general.
In addition, most physicians have lost a colleague, friend, or family member to COVID-19. All physicians taking care of COVID-19 patients have lost patients, some rather suddenly after the onset of the disease. Living and working in this environment is stressful and depressing for all involved. Physicians must be aware and alert to signs and symptoms of depression in themselves and others and be ready to take preemptive steps, i.e., seeking/recommending counseling.
The following comments are not particular to cardiothoracic surgeons, but to all practicing clinicians. “Governments” at local, regional, state, and federal levels worldwide are affected by regulatory agencies, such as the World Health Organization, Centers for Disease Control and Prevention, Food and Drug Administration, Center for Medicare and Medicaid Services, and many others, as well as multiple health advisory boards. During times of disaster, including the recent COVID-19 pandemic, governments and agencies respond with many layers and silos of emergency response committees. During this year, physicians have found themselves on a COVID-19 roller coaster as these various groups attempt to understand, slow, and advise on treating this epidemic. Hospital administrators establish, then frequently change, policies to remain compliant with government policies. As new surges of the disease emerge, policies change, adding to the frustrations and confusion already inherent with the COVID-19 challenges for physicians. Almost from day one of the pandemic, physicians, as well as the general public, were bombarded by a variety of local and national trends, fads, and rumors as to “best practices” and “bundles” for the treatment of COVID-19 patients. Initially, the various tests for COVID-19 were time consuming, often had to be sent off to a distant city, + and were considered unreliable. Furthermore, there were no proven antivirals, no specific proven and tested therapies, and no vaccine. Almost daily, a new rumor or special cocktail of vitamins, elements, drugs, or serums emerged as “the best treatment for COVID-19 patients.” CT Surgeons, and indeed, all physicians, must be especially vigilant in acquiring scientifically sound information.
| Controversies|| |
Finally, the emergency, pathophysiology, evaluation, treatment, contagion, protection, and many other medical and social factors that surround COVID-19 are filled with controversy. A few of the hospital-based controversies are cited, as well as brief comments on specific controversies.
Personal protection equipment
Since the early days of COVID-19 in February–March 2020, issues related to use of PPE have been debated. The types of PPE and whether masks, TAPR, PAPR, special shoes, and special suits are effective, etc., continue to be debated by various medical specialists, administrators, and purchasing agents. The exact motivations for individual choices are never clear. There are also debates as to whether the PPE can be cleaned and reused.
Depending on the date and the country, a large variety of tests are available to determine COVID-19 status. The early tests had to be sent off and often took several days to get results, often felt not to be completely reliable. More rapid testing became available, but their reliability, too, continues to be debated. There is also debate on how long a test will be positive and how long antibodies last in the human body. Some virologists have even questioned the value of testing at all!
Types of masks
Masks are made to protect health care workers, industrialists, patients, and others. Some must be form fitted while others are one size fits all. Debate and controversy on what kind, where, and how should mask should be fitted continues.
Ultrasonography of the chest versus swan Ganz catheters
Intensivists in the United States and even some other parts of the world have tended to abandon the use of flow directed (Swan Ganz) catheters, which intensivist used to measure cardiac output, pulmonary and peripheral vascular resistance, as well as right heart pressures and pulmonary capillary wedge pressure. Such values are estimated from ultrasound obtained by a transthoracic E-fast. Patients might even be put into pulmonary edema iatrogenically from a rapidly developed fluid overload. Almost no one in the United States uses the SG Cather anymore, and with the added potential for infection when using an invasive technique, few if any have used the Swan Ganz catheter for COVID-positive patients. Debate continues.
Fluid use to combat hypotension
Numerous fluids are available to clinicians in a hospital. Some are balanced salt solutions, while others are merely variants of normal saline or even sterile water. Blood, platelets, plasma, and other solutions have been developed as part of “shock” resuscitation. Crystalloid fluids as resuscitation agents following hypovolemic (blood loss) shock have been clearly demonstrated to produce ARDS and increase incidence of death.
Value of vasopressors
As with the use of crystalloids, surgeons, anesthesiologists, and medical intensivists attempt to raise the blood pressure to preshock levels by administering up to three different vasopressors. Evidence exists that, at least, in trauma, permissive hypotension is beneficial to recovery and a better survival. In COVID-19 patients, the use of vasopressors might not be indicated in the early ICU days. Yet, another continuing debate.
Intubation versus high flow oxygen versus early extracorporeal membrane oxygenation
ICU patients are hypoxemic. This low oxygen saturation is one of the reasons these patients are admitted to the ICU, although the criteria are considerably different across the country and around the world. Early intubation was associated with a higher mortality rate in the spring and summer of 2020. Various and differing treatment protocols were developed relating to endotracheal intubation, ECMO, high flow oxygen pharyngeal catheters, and early tracheostomy (of two types). No clear best practice has emerged.
Off label use of medications
For thousands of years, doctors and medicine men have used a variety of potions, drugs, operations, etc., in attempts to treat the medical, mental, and surgical problems, particularly when there was not a recognized first runner or specific therapy. Such might be called “off label” use of a drug, device, or procedure. Often, throughout history, a condemned off label therapy ends up becoming the preferred therapy. For COVID-19 patients, there was, and continues to be, no agreed upon, clear-cut drug, device, or therapy.
Very few effective antiviral medications, particularly against COVID-19, exist. During November 2020, one antiviral drug was introduced on the market but has a complex recommended operational administration course. Whether or not antiviral drugs are going to be a major part of future therapy for COVID-19 is still controversial.
Value of convalescent plasma
Convalescent plasma has been administered to patients with acute infection from COVID-19. It is still unclear if this is beneficial, especially regarding survival.
Vitamins, steroids, basic elements, and other potions
Numerous vitamins, corticosteroids, elements, and other “off label” compounds have been used as part of a “cocktail” or “bundle” COVID treatment around the world. The value of these therapies is still controversial.
Several companies around the world have been working on a COVID-19 vaccine to produce human antibodies against this virus. At least five are either developed or under development. Some have complex storage, delivery, and administration mechanisms. It is unknown how long it will take for any of these vaccines to result in production of human antibodies, nor how long such antibodies will remain viable.
Who is in the best position to provide critical care for COVID-19 patients?
Finally, a rather blunt and rather sensitive question. Probably, over 25–30 different protocols, philosophies, approaches, and trials exist for the treatment of COVID-19 in the United States alone. Admission criteria to hospitals, special units, ICUs, isolation units, etc., vary in different cities, specialties, and hospitals. Various specialists have emerged in different places as the decision maker/primary physician for COVID-19 patients: Infectious disease specialists, hospitalists, nocturnists, anesthesiologists, cardiothoracic surgeons, medical intensivists, pulmonologists, critical care doctors, emergency physicians, pediatric intensivists, traumatologists, acute care surgeons, and others has assumed responsibility. Each has differing ideas on therapy, but little to no evidenced-base data has been brought forward to support any of these varying approaches. There is a difference among hospitals, specialties, and even physicians in the same specialty on how COVID-19 severe infections should be managed. The solution involves in an acknowledgment that there are controversies, and developing prospective randomized studies to discover the best practices is imperative.