\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Examining the impact of COVID-19 on cardiac surgery services: the
lessons learned from this pandemic}



\author[1]{Amer Harky}%
\author[2]{Runzhi Chen}%
\author[1]{Mark Pullan}%
\affil[1]{Liverpool Heart and Chest Hospital NHS Foundation Trust}%
\affil[2]{Imperial College London}%


\vspace{-1em}



  
  \date{June 14, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{}Under the unprecedented pressures of the global coronavirus
disease 2019 (COVID-19) pandemic, there is an urgent requisite for
successful strategies to safely deliver cardiac surgery. Severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in
early December 2019, and the rapid spread and emergence of this virus
has caused significant disruptions in the delivery of healthcare
services worldwide.\textsuperscript{1,2} In particular, provision of
cardiac surgery has been disproportionally affected due to reallocation
of intensive care resources, such as
ventilators.\textsuperscript{2}Additionally, patients with pre-existing
cardiovascular disease are likely to have comorbidities which are
associated with poorer clinical outcomes in confirmed SARS-CoV-2
cases.\textsuperscript{3,4} Despite this, Yandrapalli and colleagues
have reported the first case of a successful coronary artery bypass
graft (CABG) operation in a patient with asymptomatic SARS-CoV-2
infection, which offers insights into how cardiac surgery could be
adapted to solve the challenges of this pandemic.\textsuperscript{5}

In response to the burden of COVID-19 on healthcare systems in the
United Kingdom (UK), elective cardiac surgeries have been delayed owing
to the redistribution of intensive care resources and the unquantifiable
risk of acquiring COVID-19.\textsuperscript{2} Likewise, cardiac surgery
services have undergone structural remodelling into a centralised system
in an attempt to continue provisions of emergency surgery alongside
hospital management of COVID-19
patients.\textsuperscript{2}Unsurprisingly, most cardiac surgery units
across the globe have seen a sharp decline in surgeries as a result, and
one unit reported an 83\% reduction in cardiac index cases between
23\textsuperscript{rd} March to 4\textsuperscript{th} May
2020.\textsuperscript{2} Similar models have been used in Europe to
manage healthcare services and increase intensive care capacity. For
example in the Lombardy region of Italy, 16 out of 20 cardiac surgical
units discontinued services and all urgent cases have been consequently
diverted to the remaining four units for centralised
services.\textsuperscript{6} Whilst these measures have been beneficial
for supporting the focused management of COVID-19 patients, it is
important to reflect upon the future consequences of delayed elective
cardiac surgery. Indeed, such patients are likely to have progressive
conditions and further work is needed to investigate the long-term
impact of COVID-19 on mortality and morbidity in this cohort.

The case report by Yandrapalli and colleagues highlight the importance
of routine SARS-CoV-2 testing for all patients requiring cardiac
surgery, especially for detecting asymptomatic or subclinical
infections.\textsuperscript{5} Active SARS-CoV-2 infection may
precipitate an overproduction of early response proinflammatory
cytokines in post-operative period, leading to unfavourable surgical
outcomes.\textsuperscript{7,8} Moreover, preliminary studies have shown
that patients with established cardiovascular diseases may have a
greater risk of increased SARS-CoV-2 infection severity and
prognosis.\textsuperscript{9} Taken together, assessment for active
infection is crucial for risk stratification. In addition, clinicians
should consider the threshold for surgery when selecting patients for
cardiac surgery. An international, multi-centre cohort study by
COVIDSurg Collaborative which included 1128 confirmed SARS-CoV-2
patients undergoing a broad range of surgeries revealed that 30-day
mortality risk was significantly associated with the patient
demographics of male sex, an age of 70 years or older, and poor
preoperative physical health status.\textsuperscript{10} Collectively,
the risks and benefits of cardiac surgery should be carefully considered
in such patients due to higher mortality
risk.\textsuperscript{10}Alternative therapeutic procedures with rapid
discharge, such as percutaneous intervention or medical therapy, may be
more appropriate to reduce SARS-CoV-2 related mortality and nosocomial
infection risk.\textsuperscript{11}

Current evidence is limited for postoperative outcomes in cardiac
surgery cases. In the aforementioned cohort study by COVIDSurg
Collaborative, the 30-day mortality rate was
23.8\%.\textsuperscript{10}In addition, the study reported that 51.2\%
of patients had postoperative pulmonary complications, which was
associated with a higher mortality rate of 38.0\%.\textsuperscript{10}
In another case report describing an emergency CABG operation, the
asymptomatic patient succumbed to pulmonary complications arising from a
SARS-CoV-2 infection confirmed postoperatively.\textsuperscript{12} The
authors acknowledge that the undiagnosed infection may have triggered a
refractory pathological response after cardiac surgery. Indeed, recent
literature has suggested that patients with SARS-CoV-2 are at higher
risk of developing thromboembolisms, possibly mediated by the
interaction with angiotensin-converting enzyme 2 (ACE2)
receptors.\textsuperscript{13}Similarly, there is a consensus that
SARS-CoV-2 has direct adverse effects on the myocardium due to high
expression of ACE2.\textsuperscript{14} As such, SARS-CoV-2 can
potentially trigger multisystem complications which require vigilant
monitoring, especially in patients requiring cardiopulmonary bypass and
at high risk of developing thromboembolisms. Cardiac surgery patients
represent a vulnerable patient population, and this cohort may
experience worse outcomes with SARS-CoV-2 infection based on the current
available evidence. In the latest recommendation, UK currently advises
all patients who are listed for elective cardiac surgery to self-isolate
for 14 days prior to surgery date, in a measure to limit and contain the
exposure of such cohort to the smallest possibilities of acquiring
COVID-19.

Currently, the future of cardiac surgery after the pandemic is unclear
as the evidence is still emerging. However, the lessons learnt from
these unprecedented times can be taken forward to inform future service
planning. Moving forwards, routine screening of patients for SARS-CoV-2
infection will undoubtedly play a key role in identifying asymptomatic
or subclinical infections. The preoperative UK National Health Service
testing recommendations should be broadened so that all patients
undergoing cardiac surgery are screened, given the higher risk of
postoperative complications in this population. Similarly, repeat
testing is important for monitoring patients for concomitant infections.
Alongside changes to hospital protocol, service delivery will inevitably
shift. The successful application of telemedicine during the pandemic
has already been reported in the delivery of oncology
services.\textsuperscript{15} Moreover, the benefits of telecardiology
outside of the COVID-19 era have been previously reported, and
cardiology services will likely embrace the utilisation of telemedicine
for managing outpatient consultations.\textsuperscript{16} Units will
also have to address the vast backlog of surgeries caused by
cancellation of elective cardiac operations in a sustainable manner,
with adequate hospital space and personal protective equipment
availability.\textsuperscript{17} In order to resume success services,
planning for this eventuality should begin now and patients at
significant mortality risk due to delayed surgery need to be
prioritised.

Ultimately, clear guidelines should be implemented to ensure safe
resumption of surgical services, whilst also reassuring patients
concerned about safety.\textsuperscript{3} Whilst the future trajectory
of this pandemic is uncertain, the insights from the impact of COVID-19
on cardiac surgery will undoubtedly shape the future delivery of cardiac
surgery.

\textbf{References}

1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China. \emph{Lancet} .
2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5

2. Mohamed Abdel Shafi A, Hewage S, Harky A. The impact of COVID-19 on
the provision of cardiac surgical services. \emph{J Card Surg} . May
2020. doi:10.1111/jocs.14631

3. Khan IH, Zahra SA, Zaim S, Harky A. At the heart of COVID-19. \emph{J
Card Surg} . May 2020:jocs.14596. doi:10.1111/jocs.14596

4. Guan WJ, Liang WH, Zhao Y, et al. Comorbidity and its impact on 1590
patients with Covid-19 in China: A Nationwide Analysis. \emph{Eur Respir
J} . May 2020. doi:10.1183/13993003.00547-2020

5. Yandrapalli S, Cooper H, Malekan R. Successful Coronary Artery Bypass
Operation in a SARSCOV-2 Infected Patient with Acute Coronary
Syndrome.\emph{J Card Surg} . 2020.

6. Bonalumi G, di Mauro M, Garatti A, Barili F, Gerosa G, Parolari A.
The COVID-19 outbreak and its impact on hospitals in Italy: the model of
cardiac surgery. \emph{Eur J Cardiothorac Surg} . 2020.
doi:10.1093/ejcts/ezaa151

7. Jose RJ, Manuel A. COVID-19 cytokine storm: the interplay between
inflammation and coagulation. \emph{Lancet Respir Med} . 2020;0(0).
doi:10.1016/S2213-2600(20)30216-2

8. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of
patients undergoing surgeries during the incubation period of COVID-19
infection. \emph{EClinicalMedicine} . 2020;21.
doi:10.1016/j.eclinm.2020.100331

9. Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular
metabolic diseases on COVID-19 in China. \emph{Clin Res Cardiol} .
2020;109(5):531-538. doi:10.1007/s00392-020-01626-9

10. Nepogodiev D, Glasbey JC, Li E, et al. Mortality and pulmonary
complications in patients undergoing surgery with perioperative
SARS-CoV-2 infection: an international cohort study. \emph{Lancet} . May
2020. doi:10.1016/S0140-6736(20)31182-X

11. Haft JW, Atluri P, Alawadi G, et al. Adult cardiac surgery during
the COVID-19 Pandemic: A Tiered Patient Triage Guidance
Statement.\emph{Ann Thorac Surg} . April 2020.
doi:10.1016/j.athoracsur.2020.04.003

12. Rescigno G, Firstenberg M, Rudez I, Uddin M, Nagarajan K, Nikolaidis
N. A case of postoperative covid-19 infection after cardiac surgery:
Lessons learned. \emph{Heart Surg Forum} . 2020;23(2):E231-E233.
doi:10.1532/HSF.3011

13. Khan IH, Savarimuthu S, Tsun Leung MS, Harky A. The need to manage
the risk of thromboembolism in COVID-19 patients. \emph{J Vasc Surg} .
May 2020. doi:10.1016/j.jvs.2020.05.015

14. Zaim S, Chong JH, Sankaranarayanan V, Harky A. COVID-19 and
Multiorgan Response. \emph{Curr Probl Cardiol} . 2020.
doi:10.1016/j.cpcardiol.2020.100618

15. Shirke MM, Shaikh SA, Harky A. Tele-oncology in the COVID-19 Era:
The Way Forward? \emph{Trends in Cancer} . 2020.
doi:10.1016/j.trecan.2020.05.013

16. Molinari G, Molinari M, Di Biase M, Brunetti ND. Telecardiology and
its settings of application: An update. \emph{J Telemed Telecare} .
2018;24(5):373-381. doi:10.1177/1357633X16689432

17. Frankel WC, Nguyen TC, Weiss AJ. Charting a Safe and Expeditious
Course Back to Elective Cardiac Surgery During the COVID-19
Pandemic.\emph{Innovations (Phila)} . June 2020:1556984520930066.
doi:10.1177/1556984520930066

\selectlanguage{english}
\FloatBarrier
\end{document}

