Commentary: Implications of coronavirus disease 2019 (COVID-19) for cardiac surgery: Priorities and decisions

Keshava Rajagopal, MD, PhD

Central Message.

The COVID-19 pandemic has caused cardiac surgeons to reassess their duties and priorities.

वेदमनूच्याचार्यो अन्तेवासिनमनुशास्ति

सत्यं वद धर्मं चर

vedamanuuchyaachaaryo antevaasinamanushaasti

satyam vada; dharmam chara

“Having taught the Vedas, the teacher exhorts the disciple: Speak the Truth. Perform the Duty.”

—Taittiriya Upanishad 1.11 (c. 400-600 BC)

See Article page 937.

It is straightforward that one ought to speak the truth and perform one's duty. These ideals permeate almost all faiths and philosophies. But almost all of them leave 2 questions unanswered, because those questions have answers that vary according to individual circumstances. These are: what are one's duties (ie, how can they be identified), and how should numerous duties be prioritized? Crises offer such opportunities for reflection.

In this issue of the Journal, the cardiac surgical faculty of Columbia University-Presbyterian Medical Center offer their perspectives on prioritization of duties in the context of the coronavirus disease 2019 (COVID-19) pandemic.¹ Briefly summarized, emergent cardiac operations continued to be undertaken, urgent operations were stratified according what was in good faith deemed necessary to be undertaken for patients to safely live outside the medical center environment, and “elective” operations were deferred (“elective” is in quotation marks because one could reasonably argue that nothing in cardiac surgery is truly elective, even those operations that are performed prophylactically, in the absence of current symptomatic or physiologic derangements). Other centers have adopted such policies, but the rationales provided in this report are particularly thoughtful and instructive. Specifically, although we have a good sense of what is emergent, differentiating truly urgent from semi-urgent from elective is difficult. Reasoning, data regarding the timely operative versus delayed operative versus nonoperative histories of disease, and individual surgeon experience all ought to inform the development of criteria.

The experience reported embodies honesty and duty. However, some questions remain. Why have we drastically decreased operative volumes during the COVID-19 pandemic if the majority of our work is “life-saving?” The fact that operative volumes have been intentionally decreased suggests that we have concluded that in-hospital care of patients afflicted with COVID-19 is more life-saving and important than the vast majority of cardiac surgical procedures. It is possible that our work, in the context of the resources required, in fact does not save many lives, particularly relative to less resource-intensive nonoperative treatments. It is worth noting that the greatest contributors to improved human life expectancy relate to simple public health initiatives: public sanitation (separating potable water from waste), modern obstetric and perinatal care (particularly aseptic technique), immunization, and antimicrobial drugs. Cardiac surgery is a comparatively small contributor to these improvements. Yet, unlike many other fields within medicine, in cardiac surgery, our work disproportionately saves lives, and does so acutely. We then need to ask at least 2 questions as a general matter, not simply in the context of an active pandemic. First, within an academic cardiac surgical service, should life-saving operations always be prioritized (if this were so, perhaps transplants would be performed more commonly during the day, and many general adult cardiac operations would be performed at night), and not just prioritized, but actively sought out from referring centers (which would increase urgent and emergent operative volumes further, and decrease or at least delay less urgent or elective cases)? Second, the aforementioned question should be posed across service lines—between cardiac surgery and general thoracic surgery, or vascular surgery, or general surgery; if so, concepts such as operating rooms dedicated to specific services or surgeons, or “block time,” become obsolete.

On the other hand, coming back to the COVID-19 pandemic, is it possible that decision-making is faulty? Should elderly patients or those with multiple comorbid conditions, both of whom have diminished hospital and long-term survival in comparison with younger and healthier patients, undergo intensive care unit admission, invasive mechanical ventilation, or more advanced care? If the answer to that question is no in general, then the negative impact of the pandemic upon cardiac surgery and other disciplines would be far less. And thus, although honesty and duty are necessary conditions, they are not sufficient. We have to humbly ask and answer the difficult questions of what our duties ought to be, and how to prioritize them.