A new normal
The pandemic affects our daily routine as cardiac surgeons in multiple ways: limited intensive care unit (ICU) beds and ventilators, necessity to postpone elective and/or complex cardiac surgeries, shortage of healthcare workers, sickness of healthcare staff and/or risk of infection of our Teams, risk of developing COVID-19 after cardiac surgery, and patients with COVID-19 needing urgent cardiac operations without having a properly organized operating room and ICU. The pandemic has hit every health system and the first bailout strategy was to maximize available ICU resources by discontinuing elective surgical activity. As Cardiac Surgeons, treating potentially life-threatening conditions on a daily basis, we seek direction from the National Cardiac Surgery Societies: nothing has been clearly stated about the triage process in severe valvular diseases. We believe that a comprehensive reorganization of our activities should be considered. Indeed, the system should aim to keep as much as ICU resources available for COVID-19 patients and at the same time, segregate the positive COVID-19 cases.
Should we consider a “regional” reorganization as well as a“hospital” reorganization? For example, consider the “hub center” system established in Lombardy (Italy) in the beginning of March by the Regional Government. They identified 18 hub Centers that would address the urgent and emergent pathologies, leaving the other hospitals available for COVID-19 patients. This setting may have some drawback: Hospital chains may be able to reorganize and distribute patients to specific centers, only if both expenses and profits can be equally shared. Moreover, this may not be sustainable with individual stand alone institutions. As far as “hospital” reorganization, every Institution has been allowed to determine the proper pathway upon which to open their operating schedules as long as the procedure is not deferrable for more than 1 month.
We are heading to a new normal , working through the SARS-CoV-2 era, adjusting our daily practices with various safety measures. This also means being ready to face future waves of the pandemic and to working amongst a population with a small but still present portion of positives. We have to be prepared to preserve the safety of health care workers and hospital admitted patients, while having dedicated OR, ICU and ward beds to treat COVID-19 patients: indeed, the access to a proper and timely treatment cannot depend on the outcome of a swab.
To reach those goals, it is necessary to screen and segregate the positives with dedicated pathways for further diagnostic testing and treatment, regardless of the admitting diagnosis. A committed health care team would be ideal: chosen among the immunes (if this coronavirus generates a consistent and persistent immune response) or among those with less risk factors to develop a severe COVID-19. To stress this idea, the foundation of a SARS-CoV-2 Hub Center seems to be an option to eradicate the risk of in-hospital infection in non-COVID-19 patients, who are the most at risk. Regarding pathologies that merit priority for urgent treatment, it’s reasonable to focus on those valvular diseases that directly may have an associated degree of pulmonary hypertension (PH). PH associated with left heart disease (Nice group 2) is by far the most common cause of PH and accounts for 50–85% of the cases. Left-sided valvular heart disease can cause an elevation of the left atrial pressure which usually leads to post-capillary PH, which is passively transmitted backward toward the pulmonary venous system. Based on the pathological findings and on the suspected mechanism of lung damage, an increased pressure in the pulmonary artery may further compromise the effective oxygen/carbon dioxide exchange in the alveoli. Then, severe mitral regurgitation (MR), severe mitral stenosis (MS) and severe aortic stenosis (AS) are the main pathologies to focus upon. In severe primary MR about 20-30% of patients have systolic pulmonary artery pressure (sPAPS) >50 mmHg; secondary MR sees an slightly higher prevalence of severe PH(12). Approximately 65% of patients with symptomatic severe AS develop some degree of PHT, with the prevalence increasing to 80% in octogenarians because of chronic elevation of left ventricular end diastolic pressure; a more severe degree of PHT is present in about 15% of AS patients. Rest echocardiography is essential to assess the presence of pulmonary hypertension in the symptomatic patient. On the other hand, in order to correctly identify and stratify asymptomatic patients with a degree of pulmonary hypertension, exercise echocardiography is crucial. The prevalence of PH almost doubles under effort in patients with mitral regurgitation and increases almost 10 fold in asymptomatic patients with severe aortic stenosis(12).