The importance of Coronavirus Disease 2019 testing in cardiac surgery

To the Editor:

The authors reported no conflicts of interest.

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The extraordinary demands for managing patients with Coronavirus Disease 2019 (COVID-19) has altered the Italian hospitals' ability to provide adequate care. With exponential increase of the COVID-19 population and a progressive reduction of resources, the ability to provide surgical care has been rapidly decreased.¹ Although several surgical organizations developed guides for triaging patents with cancer, the selection of candidates for cardiac surgery poses major challenges given the rapid progression of the underlying disease and the uncertain evolution of organ failure.^{2 , 3}

Haft and colleagues⁴ provided an important guidance to adult cardiac surgeons regarding the triage of patients with cardiac disease. The document presents some useful general rules to optimize hospital resources.⁴ However, little attention is still given to these frail patients at high risk for COVID-19 infection and dissemination. Moreover, no clear indication exists regarding the preoperative screening tests to be performed before surgery with significant variations in practice according to each institution.⁴ Our department of cardiac surgery is a tertiary referral center providing cardiac service to approximately 660,000 people in the region of Piedmont, in the northwest of Italy. Our hospital was initially COVID-19 free, but, given the large increase of infected patients, it was rapidly involved in the management of these patients. However, as per hospital policy, patients admitted for cardiac surgery were not tested for COVID-19 because they were receiving elective but not deferrable surgery. From February 1 to April 15, 100 patients were admitted to our cardiac surgery department. They were all symptomatic with a high prevalence of New York Heart Association III or at high risk for rapidly progressive disease. At hospital admission, patients received routine laboratory tests and chest x-ray but no specific test for COVID-19. No patient showed any COVID-19–related symptoms at the time of surgery. Among operated patients, 4 of them developed symptomatic COVID-19 infection during hospitalization. One of them required intensive care unit admission. In the same time period, 5 of 8 cardiac surgeons, 1 of 9 cardiac anesthesiologists, and 7 of 48 nurses became COVID-19 positive and symptomatic. This has progressively led to a dramatic reduction in the department activity, with a 75% of reduction of the daily surgical and clinical caseload. Such dispersion of resources has consequently led to decentralization of care and a delay of surgical treatment, with 6.6% of patients who died while on the waiting list. Thus, our healthcare institutions should focus more on the triage of patients with cardiac disease, considered at high risk of COVID-19 infection. These patients should mandatorily receive microbiological tests for COVID-19, even in the presence of unstable conditions, to decrease the risk of viral dissemination and depletion of resources.