Cardiac Surgery Model During COVID-19 Pandemic: Now It’s Time to Ramp Up

To the Editor:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly from China¹ worldwide and on March 11, 2020, the World Health Organization declared the so-called COVID-19 a pandemic. In Italy, the first cases occurred at the end of January and on June 14 there were 235,989 infected patients with 34,345 deaths (14.5%), representing the third country with the highest number of infections, after the United States and Spain.

Due to the high contagiousness of SARS-CoV-2, an impressive increase of hospitalizations occurred. All kind of surgery units stopped treating elective cases, focusing instead on urgent/emergent patients to minimize intensive care unit bed utilization. Patients with underlying cardiovascular diseases have an increased risk of developing the severe form of COVID-19,² and health care workers are exposed to the risk of contagion or of becoming vectors of transmission.

The Italian government imposed a nationwide lock-down on March 9. Emilia-Romagna is the region with the third highest number of infections, after Lombardy and Piedmont, and the S.Orsola Hospital, University of Bologna, became the main regional hub center for COVID-19. Between January 1 and April 30 we operated on 273 adult patients. Our activity was reduced by only 30% thanks to a cooperation with a “COVID-free” private clinic.

We treated only urgent/emergent cases or those whose treatment was considered not postponable for more than a month. We also performed 8 heart transplants, 3 left ventricular assist device implantations, and 3 pulmonary artery thromboembolectomies.

In-hospital mortality was 1.1% (n = 3 of 273). None of our patients were infected during hospitalization. Four patients (1.4%) became positive during the rehabilitation in other hospitals, and one of these patients died.

Actually, in our center, each patient undergoes nasopharyngeal swab 1 day before hospitalization. If the test is positive the patient is not admitted and the operation postponed. If there is an emergent case, a nasopharyngeal swab is performed and the patient is considered suspect until the result of the test. In case of cardiac transplant, the recipient undergoes nasopharyngeal swab and also high-resolution computed tomography of the chest. We created a specific “COVID-19 route” for suspected patients, with dedicated intensive care unit beds and 1 operating room.

At the time of writing, here in Italy new COVID-19 cases have begun to decline, showing a “flattening of the curve”, and the nationwide lockdown was lifted on May 4. Deciding when and how to resume non-urgent health care delivery can be challenging, but we strongly think that hospital systems should put effort in resource reorganization: COVID-19 slowed down our country but cardiac surgery has to find a way to ramp up again for the sake of patients awaiting treatment.