Abstract
The COVID-19 pandemic has remarkably impacted the hospital management
and the profile of patients suffering from acute cardiovascular
syndromes. Among them, acute infective endocarditis (AIE) represented a
rather frequent part of these urgent/emergent procedures. The paper by
Li and colleagues has clearly shown the higher risk features which
patients with diagnosis of AIE presented at hospital admission during
the first part (first and second waves) of the outbreak, often requiring
challenging operations, but fortunately not associated with worse
outcome if compared to results obtained prior to the SARS-2 pandemic.
The report discussed herein presents several other aspects worth of
discussion and comments, particularly in relation to hospital management
and post-discharge outcome which certainly deserve to be highlighted,
but also further investigations.
As well-known, besides the unprecedented impact of the COVID-19
worldwide pandemic with regards to patients experiencing a variety of
clinical compromise due to the infective illness, lack of dedicated beds
and equipment to face overwhelming hospital admittance for respiratory
dysfunction, delay in hospital admission of patients with other
illnesses, and reduced hospital activities for non-COVID-related
treatments, were also described as severe consequences during the
outbreak with inevitable suboptimal patient
management1-5.
Li and colleagues have reported a single-centre, retrospective, and
comparative study looking at two-year series of patients requiring
surgical treatment for acute infective endocarditis (AIE) just prior or
just after the start of the COVID-19 pandemics6. The
findings of this study clearly confirm that patients admitted with a
suspicion of AIE had a more critical cardiac as well as general clinical
conditions at admittance during the pandemic. This translated into
higher risk, more complex operations, and longer ICU as well as
in-hospital stays. The good news is that this more challenging scenario
did not eventually lead to higher in-hospital mortality. This is
accordance with the study of Nader and associates who showed a higher
risk profile and active endocarditis during the SARS-2 outbreak,
characterized also by a more complicated perioperative
course4, data also confirmed by the Italian national
survey3.
Despite the reassuring early outcome of the study of Li and associates,
however, there are still some major issues which will deserve further
comments and, hopefully, additional investigations and data. Are these
patients, despite not worse in-hospital outcome, more prone to
recurrence of AIE or other post-discharge complications or even less
favorable outcome? Are these patients experiencing additional
shortcomings related to the suboptimal pre-operative delayed management
and more complex profile? Is the more complex treatment and operations
going to influence the post-discharge late clinical conditions? These
questions are unfortunately not met in the Li’s and associates’
investigation and would require ad hoc research.
We are aware that all medical specialties have been somehow hit by the
overall COVID-19 illness, particularly during the first pandemic wave,
perhaps also potentially affecting the overall quality of care of the
treated patients based on the overwhelming pressure exerted by the
pandemic itself. Nonetheless, acute cardiovascular syndromes, and, among
them, AIEs, may have suffered from a significant cluster of suboptimal
organization and management due to the hustles observed in daily health
care provision1-3.
Another interesting aspect might be related to the in-hospital acquired
COVID-19 in these patients, apparently not described by Li and
collaborators. Wrong diagnosis of COVID-19 illness, delaying an
AIE-related recognition, or the combination of the two conditions,
making clinical management even more challenging8,
have been described. Furthermore, patients treated for AIE were at risk
also for in-hospital acquired COVID-19 infection, although this event
was really limited in the Li’s and other series5-7.
There is no doubt that all the non-COVID-19 illnesses, particularly the
acute cardiovascular syndromes, have been accounted with a sort of
shadow or darkness, and, only recently, the SARS-2 COVID “collateral
damages” have been coming to the surface, indicating how many of these
situations, with patients either suffering from a voluntary or
hospital-based delayed admittance or consideration, occurred during the
COVID pandemic9. Several papers have described the
well-known shut-down or remarkable reduction of cardiac surgical
programs, with the obvious and sadly known
consequences1-3. Delayed treatment of acute myocardial
infarction, with its potentially fatal or life-threatening
complications, or of AIE-related conditions, either for the fear of the
patients themselves to refer at the COVID-19 overwhelmed health care
structures or initially left home to reduce the ongoing patient
burden/flow to the “drowning” hospitals, have been
described9
The rather stable number of AIE patients, when comparing the period
prior to the pandemic and the first and second waves, as described in
the paper of Li and colleagues5, should not prompt to
the conclusion that COVID-19 was not influencing the overall rate of AIE
or nor responsible for such an illness. It is however true that, among
the overall cardio-vascular complications attributed to COVID-19 virus,
AIE does not represent a widely reported event, rather, no clear
relationship has been described or conclusively demonstrated.
Interstitial compromise, like capillary microthrombosis, or inflammatory
state-related conditions, like acute myocarditis or pericarditis and
tamponade, have been the vast majority of conditions reported as far as
COVID-19 and cardiac compromised is concerned9,10.
Antother important aspect highlighted by the paper of Li and colleagues
accounts for the relevance of the multi-disciplinary and dedicated team,
namely the Acute Endocarditis Team, plays a critical role in the
appropriate management and therapeutical success of such complex
patients, as already underlined by other several
series/experiences4. Today, even amid difficult
organizational and hospital-related pressure, technology may help health
care professionals to reduce decision-making times and subsequent
treatment which may compensate organizational and disease-related
uncertainties and delay. Remote or online case-presentation, together
with the dedicated team discussion, may favor or partially compensate
delayed management, although prompt diagnosis and therapies remain the
major contribution to successful acute cardiac diseases.
Obviously, country-based or regional circumstances may constitute
additional hustles in the appropriate chain-of-handling of patients with
AIE. This has been also properly highlighted by Li and colleagues,
showing all the aspects which caused delayed in these difficult
times4. Likewise, this experience underlines the
peculiar circumstances AIE patients may experience, which represent
well-known factors predisposing the patients to final potentially lethal
conditions, like acute heart failure, septic shock or even cardiac
arrest. Finally, the patient transfer organization was certainly also
seriously reduced or inefficient based, again, on the dramatically
superior number of patients affected by COVID-19, and considered at
higher priority with respect to all the other patients. This particular
aspect should represent a remarkable and sensitive aspect for the health
care administrator and organizations to be able, in the future, to
preventively design and arrange crisis-based strategies in order to
avoid “privileged” patients, more based on the ongoing emotion rather
than actual needs and level of urgency/emergency, as unfortunately
observed during the past two years.