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Humanity is witnessing the Coronavirus disease 2019 (COVID-19) pandemic
which no one ever imagined in their wildest of dreams. It is an evolving
global threat and its future course appears to be unpredictable to say
the least. As of April 18, 2020, there have been 20,78,605 confirmed
cases of COVID-19 with 1,39,515 confirmed deaths reported worldwide and
still counting.1
Although the exact clinical course, severity, and complications of
COVID-19 are not yet completely determined but the risk of mortality is
seen to be higher in males, age >60 years and those with
underlying co-morbid conditions like diabetes mellitus, underlying
cardiac or lung disorder, and any immunocompromised
state.2 This fact is of critical importance for any
healthcare provider dealing with cardiac sciences, more so for cardiac
surgeons.
The exponential rate at which this situation is evolving has forced us
to ask some critical questions about our preparedness.
This is an extraordinary situation which requires extra-ordinary
measures. There is a global call for deferring the elective cardiac
surgeries. The very step to postpone cardiac surgeries can be argued
upon. There are three critical factors favoring deferring of such
procedures. Firstly, it will help in the containment effort by reducing
the travel of patient with accompanying relatives to the hospital which
are hotspots for severe acute respiratory syndrome Coronavirus-2
(SARS-CoV-2). Secondly, reducing the number of elective procedures will
preserve the essential medical supplies, intensive care unit (ICU) beds,
ventilators, personal protective equipments (PPE), which can be utilized
for dedicated COVID-19 units. Preserving protective equipment and
clinicians is key in containing outbreak. Thirdly, cardiac surgeries
utilize a large pool of blood components of the hospital and in this era
of pandemic, the numbers of blood donors have reduced substantially.
Thus, by avoiding elective cardiac surgeries, can help in preserving
them for emergency cases
Coronaviruses are known to affect the cardiovascular system. Novel
coronavirus, SARS-CoV-2 has been shown to affect the cardiovascular
system by a number of mechanisms such as eliciting an intense systemic
inflammatory response syndrome (SIRS), plaque instability and even
direct cytotoxic effect on myocardium leading to
myocarditis.3, 4 It is well known that acute
deterioration in lung function leads to increased cardiac workload and
thus de-stabilizes underlying chronic cardiovascular diseases (CVDs).
Therefore, SARS-CoV-2 affects the cardiac patients in a dual manner.
Firstly, by causing severe acute respiratory syndrome (SARS), it creates
extra workload on already diseased myocardium. Secondly, by inducing
myocarditis it furthers depresses cardiac function. The decreased
cardiac function in turn worsens lung function further, starting a
vicious cycle in which SARS-CoV-2 acts as a catalyst, especially in
cardiac patients.
Cardiopulmonary bypass (CPB) induces SIRS which is known to depress
myocardial function and lung injury.5 Further it has
been observed that SARS-CoV-2 is associated with a high inflammatory
response.3 Thus, a nosocomial SARS-CoV-2 infection in
a patient operated for an elective cardiac surgery under CPB can be
lethal.
While there is a general consensus for postponement or delaying the
elective cardiac surgeries, however defining elective cardiovascular
procedures in the era of COVID-19 outbreak is not so straightforward. A
number of guidelines are emerging globally highlighting various
mechanism to triage cardiac patients requiring
interventions.6 Each hospital should make their own
standard set of guidelines which is best suited for their infrastructure
and population to triage the cases.
Till the time a standard set of guidelines become available we recommend
deferring the ‘deferrable’ cases. We believe performing percutaneous
coronary interventions (PCI) and other endovascular procedures and
resorting to surgical intervention only as a last ditch stand will be
beneficial in the present scenario. While being on the back foot, for a
cardiac surgeon, in this extraordinary situation of global pandemic
makes more sense but at the same time we should work extensively towards
preparing an exit strategy because although COVID-19 emerged as an acute
infectious disease but it may soon become a chronic epidemic similar to
influenza due to genetic recombination.