Corresponding author:
Stanley Tam, MD
Steward Center for Advanced Cardiac Surgery at St Elizabeth’s Medical
Center.
11 Nevins Street suite 306
Brighton, MA 02135
(617) 789-2045
Stanley.Tam@steward.org
ABSTRACT
In this report we describe the clinical presentation, laboratory
findings and outcomes of four patients that were referred for urgent
cardiothoracic intervention and tested positive for COVID-19. Though the
majority of the patients undergoing surgery had low Society of Thoracic
Surgeons score and uneventful operating time, mortality was very high
and driven primarily by the viral syndrome. Laboratory markers that have
been associated with disease severity in the general population were
also prognostic in our population. Our study shows that these patients
have very high mortality, whereas prevention and preoperative screening
is required in preventing nosocomial spreading of the disease.
INTRODUCTION
Although the majority of elective surgical interventions have been
postponed during the COVID-19 pandemic, many patients are referred to
tertiary centers for emergent cardiothoracic interventions. To-date,
data on the perioperative management of these patients are limited.
Initial reports from Asia showed that patients with cardiovascular
disease are increased risk for COVID-19 related mortality (1-2). In
parallel, the majority of cardiothoracic patients presents with symptoms
that resemble severe respiratory illness, posing a diagnostic challenge.
Further, immune suppression due to cardiopulmonary bypass puts patients
into high risk for complications. Finally, ethical challenges regarding
cardiopulmonary resuscitation in the perioperative course often arise.
The expert society guidelines on optimization strategies for
perioperative management of COVID-19 positive patients are underway.
(3-4) Our study shows that cardiothoracic patients have very high
mortality which is driven primarily by the viral infection, whereas
prevention and preoperative screening is required for improving
outcomes.
CASE DESCRIPTION
Case 1
An 83-year-old female with past medical history (PMH) significant for
carotid artery disease s/p endarterectomy, stage IV chronic kidney
disease and STS mortality score of 15.224% who presented with new onset
lower back pain and SOB. The patient was found to have NSTEMI, and acute
congestive heart failure (CHF). Decision was made to undergo coronary
artery bypass graft (CABG) procedure of four vessels. On hospitalization
day (HD) 8 during the cardiothoracic procedure, a nasopharyngeal swab
for rapid SARS-CoV-2 PCR was performed and resulted positive. There were
no intraoperative concerns. The separation from cardiopulmonary bypass
(CPB) was uneventful. On postoperative day (POD)1 the patient was
extubated. On POD2 patient complained for diffuse abdominal pain and
developed leukocytosis, coagulopathy, lactic acidosis, transaminitis and
acute renal failure requiring dialysis. Repeat TTE showed unchanged
cardiac function and structure. Her course was complicated by multiple
episodes of arrhythmias including atrial fibrillation and ventricular
ectopies. On POD 3, Intra-aortic balloon pump was inserted with partial
improvement of hemodynamic status. On POD 4 the patient suffered a
cardiac arrest and got reintubated during ACLS. Palliative care was
consulted and decision for comfort measures was made. The patient
expired on POD 5.
Case 2
A 70-year-old male with PMHx of aortic stenosis s/p transaortic valve
replacement, atrial fibrillation, complete heart block s/p pacemaker,
CAD s/p CABG, chronic CHF and STS mortality score rate of 9.029% who
presented with confusion and paralysis. MRI brain showed bilateral
multiple small acute cerebral infarcts. Blood cultures were positive for
gram-positive cocci in chains and pairs. A transthoracic echocardiogram
showed severe aortic stenosis with an aortic root abscess and rocking
bioprosthesis in the aortic position. His pacemaker was explanted. Chest
x-ray was significant for pulmonary vascular congestion and patch
bilateral airspace opacities. On HD 8 a screening test was positive. The
patient was transferred to the ICU for subsequent medical management as
a bridge therapy for aortic valve and aortic root replacement. The
patient was experiencing chest pain during his ICU hospitalization and
decision was made to proceed with the surgery due to the unstable valve.
He did not have clinical signs of ARDS. The day of the surgery (HD 13),
before coming to the operating room (OR), the patient developed
pulseless ventricular fibrillation. The patient passed away within 30min
from ACLS initiation.
Case 3
A 66-year-old male with PMH of hypertension, obstructive sleep apnea,
diabetes mellitus, CHF, atrial fibrillation, alcohol abuse and STS
mortality score rate of 2.708% who presented with progressively
worsening SOB, chest pain, nonproductive cough, and lower extremity
edema. On admission COVID-19 screening was negative. He was diagnosed
with acute CHF. Echocardiogram showed an EF of 26% and cardiac
angiogram revealed multivessel disease. The patient had on pump CABG x5
and left atrial appendage exclusion. Separation from CPB was uneventful
and the ACT was zero. On POD 1 the patient had increased oxygen
requirements. On POD 7 and HD 17 COVID-19 nasopharyngeal PCR was
performed and was positive. On POD 15 he was re-intubated secondary to
severe ARDS (PAO2/FIO2 ratio of 67.5), he developed severe hemodynamic
instability, fever, and multiorgan failure. The patient expired on POD
35.
Case 4
A 46-year-old male without PMH who presented with acute chest and back
pain radiating to the left lower extremity and diagnosed with Stanford
type A aortic dissection. His STS mortality score was 2.575% with up to
17% 30 day mortality of the surgically corrected aortic dissection.
Bilateral ground glass opacities where noted on preoperative CT scan. On
admission, rapid COVID-19 PCR was positive. Emergent ascending aorta
repair with tube graft was performed. Separation from CPB was uneventful
and ACT was zero. The patient was transferred to the cardiothoracic ICU
in stable condition and got extubated on POD1. On POD4 the patient
became persistently febrile (Tmax:103 F) until POD14. Further infection
workup was negative. The patient clinically improved and was discharged
to a step-down surgical unit on POD 15.
SERUM MARKERS:
We followed the inflammatory markers and other serum markers that have
been associated with disease severity and mortality. The results are
presented in Figure 1.
CONCLUSION:
In this report, we describe our institution’s experience with four
patients that were tested positive for COVID-19 within the perioperative
period. Although the patients’ perioperative mortality rate was
2.575-17% and had an uneventful intraoperative course, three out of
four patients expired secondary to causes attributed primarily to
COVID-19 complications.
Interestingly, all patients presented with symptoms that were attributed
to their cardiothoracic pathology. Screening during the perioperative
surgery revealed the COVID-19 infection, providing further support to
the Joint Statement guidelines (5). Although cancellation of the surgery
due to the diagnosis of COVID-19 infection would not be always possible
in our population, our experience suggests that it should affect the
decision of postponing the procedure when possible.
Cardiothoracic patients are transferred to the ICU postoperatively,
require intensive nursing care and many times develop arrhythmias that
require advance cardiac life support (ACLS). These interactions can
potentially result in high exposure of staff to COVID-19. In the
reported cases, droplet precautions were not placed until after
diagnosis, resulting up to a total of 408 hours of interactions without
appropriate PPE. Furthermore, a dilemma that we faced was initiation of
ACLS in cases that further interventions were considered futile.
Markers that have been associated with disease severity were applied to
our population (2). We found that D-dimer and fibrinogen reached nadir
on POD 3-5. After this timeframe, markers up-trended in patients that
developed severe COVID-19 clinical syndrome. This observation suggests
that D-dimer and fibrinogen can be used as surrogates of severe COVID-19
in this population.
The limitations of our study include the small sample size and the
observational profile. Nevertheless, our experience identified several
areas of quality improvement, and institutional screening practice
changes. Further, our data support implementation of COVID-19 infection
in the STS score for mortality assessment. Larger studies are needed to
address mortality, prognostic markers, and peri-operative
anticoagulation for COVID-19 cardiothoracic patients.
REFERENCES
- Aghagoli G, Gallo Marin B, Soliman LB, Sellke FW. Cardiac involvement
in COVID-19 patients: Risk factors, predictors, and complications: A
review. J Card Surg . 2020;10.1111/jocs.14538.
- Rescigno G, Firstenberg M, et al.. A Case of Postoperative Covid-19
Infection After Cardiac Surgery: Lessons Learned. Heart Surg
Forum . 2020;23(2): E231‐E233. Published 2020 Apr 21.
doi:10.1532/hsf.3011
- Engelman DT, Lother S, George I, et al. Adult Cardiac Surgery and the
COVID-19 Pandemic: Aggressive Infection Mitigation Strategies are
Necessary in the Operating Room and Surgical Recovery. Ann
Thorac Surg . 2020; S0003-4975(20)30587-7.
- Haft JW, Atluri P, Alawadi G, et al. Society of Thoracic Surgeons
COVID-19 Taskforce and the Workforce for Adult Cardiac and Vascular
Surgery, Adult cardiac surgery during the COVID-19 Pandemic: A Tiered
Patient Triage Guidance Statement, The Annals of Thoracic Surgery
(2020),
- Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19
Pandemic
American College of Surgeons American Society of Anesthesiologists
Association of periOperative Registered Nurses American Hospital
Association