Letter:
To the Editor:
We have read the article by Ana Lopez Marco et al.1 entitled ”Early
experience of aortic surgery during the COVID-19 pandemic in the United
Kingdom: A multicenter study” with great enthusiasm and interest. 1 This
manuscript, which is concise and insightful for readers, is the result
of the authors’ extraordinary efforts. We concur with the conclusion
that the service provision for aortovascular pathologies shifted during
the early months of the pandemic while maintaining urgent and emergency
care. The combination of the preoperative COVID19 screening protocol,
self-isolation, and shielding contributed to our series’s low incidence
of COVID19. During this period, surgical outcomes for aortovascular
patients are comparable to national pre-pandemic benchmarks. During the
recovery phase or future waves of the COVID19 pandemic, these findings
support the continuation of surgery for this patient population.
Nonetheless, we feel compelled to highlight specific issues that would
have significantly improved the quality of this article and influenced
its outcomes.
First, any amended pathway during the COVID-19 outbreak will need to be
optimized and convenient, with minimal use of healthcare resources and
limited exposure of the vulnerable transcatheter aortic valve
implantation (TAVI) patient to possible COVID-19 infection. Pathway
designs raise several questions, including should case selection be
altered, should the work-up be changed, is there a role for balloon
aortic valvuloplasty, should the technique be performed differently, and
should the duration of stay be shortened.2 Possibly the most challenging
part of patient care is the final phase, the so-called ”recovery phase,”
because there are numerous unknown variables and any predicted timeline
at this time is pure speculation. After the peak of the COVID-19
pandemic, planning must begin for the reintroduction of the TAVI
service; however, in the absence of efficient COVID-19 treatment, strict
regulations will persist.2 There is little debate regarding the
necessity of emergency surgery for acute type A aortic dissection or
ruptured aortic aneurysm unless other factors, such as malperfusion,
prolonged shock, or advanced age, anticipate an extremely poor
prognosis. In contrast, the choice to continue operating on high-risk
thoracic aortic aneurysms, such as symptomatic, rapidly growing, or
giant aneurysms (>7 cm), as well as (saccular)
pseudoaneurysms, is significantly more complex and may be considered for
urgent surgery depending on the risk of aneurysm-related death and the
availability of resources. The surgery of asymptomatic patients with
smaller aneurysms can be delayed for two to three months.3 even though
the consensus for COVID-19 management fluctuates daily due to rapidly
changing circumstances, we strongly advocate for mandatory testing
regardless of COVID-19 symptoms or hemodynamic instability. The current
screening process will not detect COVID-19 infections in patients with
mild or no symptoms. Instead of waiting for RT-PCR results, many
surgeons may believe a negative CT for typical radiographic features
suffices as a screening for COVID-19 infection. CT imaging may be a more
reliable and practical for diagnosing COVID-19 than RT-PCR, particularly
in epidemic areas.4