Table 2.
Guidance for Adapting Cardiac Surgery Care Delivery in Response to Government Requirements, Hospital Capacity, and Infectious Disease Burden4, 5, 6,10
| Tier | Tier 3 | Tier 2a | Tier 1a |
|---|---|---|---|
| Government advisory | No cardiac surgery Mandatory shelter at home | Priority elective surgery only Social distancing | Resume all elective surgery |
| Critical care capacity | No ICU capacity Most ventilated patients have COVID Ventilated patients > ICU beds | Major restriction Many ventilated patients have COVID | Close to normal capacity No or few ventilated patients have COVID |
| SARS-CoV-2 prevalence | High or rapid increase in prevalence | Moderate or decreasing | Low |
| Coronary | |||
| Shock/OHCA | Medical management | PCI | PCI |
| STEMI | Thrombolysis | PCI with/without mechanical support | CABG/PCI as indicated |
| NSTEMI | Medical management | CABG/PCI as indicated | CABG/PCI as indicated |
| Unstable angina | Medical management | Medical management preferred unless critical left main stem lesion or equivalent, ischemic cardiomyopathy | CABG/PCI as indicated |
| Stable angina | Outpatient management | Medical management unless: Critical left main stem lesion or equivalent, ischemic cardiomyopathy | CABG/PCI as indicated |
| Valve | |||
| Aortic stenosis | Defer TAVR /SAVR Consider outside referral if symptomatic, cardiomyopathy, valve area <0.6cm2 | Defer TAVR /SAVR unless symptomatic, cardiomyopathy, valve area <0.6 cm2 | TAVR/SAVR as indicated |
| Aortic insufficiency | Defer SAVR Consider outside referral if symptomatic, cardiomyopathy, AF | Defer SAVR unless symptomatic, cardiomyopathy, increasing LV size, AF | SAVR as indicated |
| Mitral stenosis | Defer mitral intervention Consider outside referral if symptomatic, cardiomyopathy, AF | Defer mitral intervention unless symptomatic, cardiomyopathy, increasing LV size, AF | MVR /MBV as indicated |
| Mitral insufficiency | |||
| Endocarditis | Medical management Consider outside referral if heart failure, uncontrolled sepsis, conduction block, prosthetic IE | Defer surgery unless heart failure, uncontrolled sepsis, conduction block, prosthetic IE | Surgery as indicated |
| Aorta | |||
| Type A dissection | Emergency surgery if critical care bed available, otherwise seek alternate care at peer institutions with capacity | Surgery as indicated | Surgery as indicated |
| Type B dissection | Medical management unless malperfusion indicates TEVAR | ||
| Aortic aneurysm | Defer unless symptomatic, rapid growth (>0.5 cm/6 months) large size (>6 cm) | ||
| Complex | |||
| Mechanical support | Outside referral with exception of ECMO if capacity and experience permits | Defer unless decompensating heart failure | |
| Transplant | Medical management | UNOS status 1-3 only | |
| Congenital | Outside referral or medical management | Defer unless decompensating heart failure, failure to thrive | Surgery as indicated |
| Emergency (eg, coronary dissection, tamponade) | Emergency surgery if critical care bed available otherwise seek alternate care at peer institutions with capacity | Surgery as indicated | Surgery as indicated |
| Outpatient | |||
| Outpatient clinics | Limit to urgent assessment deferred and deteriorating patients, use video visits where possible | Increase use of video visits for early postoperative follow-up, close follow-up of all deferred patients | |
| Noninvasive imaging | Urgent assessment only | Assessment priority patients | Imaging as indicated |
| Invasive imaging | Emergency evaluation only | Assessment priority patients | Imaging as indicated |
AF, atrial fibrillation; CABG, coronary artery bypass grafting; COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; IE, infectious endocarditis; LV, left ventricular; MBV, mitral balloon valvuloplasty; MVR, mitral valve replacement; NSTEMI, non-ST segment elevation myocardial infarction; OHCA, out of hospital cardiac arrest; PCI, percutaneous coronary intervention; SAVR, surgical aortic valve replacement; STEMI, ST segment elevation myocardial infarction; TAVR, transcatheter aortic valve replacement; TEVAR, thoracic endovascular aortic repair; UNOS, United Network for Organ Sharing.
Tier 1 and 2 differ from those in guidance describing pre-peak response. The late phase recommendations reflect the likelihood of prolonged phase of persistent COVID-19 prevalence in hospital and community after peak phase, during which time adapting practice is preferable to deferring elective patients indefinitely.