The Outcomes of Patients Incidentally Confirmed with Covid-19 After Cardiac Surgery
Covid-19 Activation Shortly After Open Heart Surgery
DOI:
https://doi.org/10.1532/hsf.4259Keywords:
Cardiac surgery, extracorporeal circulation, Covid-19 activation, latent period, acute respiratory distress syndromeAbstract
Background: The aim of this study was to investigate the clinical outcomes of cardiac surgery in patients who were incidentally diagnosed with Covid-19 in the postoperative period.
Patients and methods: We performed 826 open cardiac surgeries in five tertiary centers. Most of the surgeries were elective coronary artery bypass grafting (CABG) (93.8%). A preoperative RT-PCR test and transcutaneous oxygen saturation were routinely investigated prior to surgery. We also investigated whether the patients already received Covid-19 treatment or had any contact with a Covid-19 patient in the last two weeks. We analyzed high sensitive C-reactive protein (hs-CRP), d-dimer, and fibrinogen, which plays a main role in the activation of procoagulant state after surgeries.
Results: Acute lung injury related to Covid-19 activation was observed in 48 out of 826 patients (5.8%). The median age of 48 patients was 63.9±12.4 years. Euro-Score and body mass index (BMI) were 6.1±1.1 and 29.2±4.1kg/m², respectively. RT-PCR test results were positive in 29 patients (60.4%). We performed thoracic computed tomography (CT) in all patients with or without positive RT-PCR test results. Thoracic CT images showed that there was a different degree of ARDS (mild, moderate, and serious). The median time of extracorporeal circulation (ECC) was 93.2±14.6 min. in on-pump surgery (IQR, 68-155 min.). Common symptoms included dyspnea (N = 22; 45.8%) and fever (N = 12; 25%). Eleven patients needed readmission to ICU. Compared with non-admitted to ICU patients, ICU patients were higher comorbidities and severe laboratory abnormalities (eg, high blood d-dimer and fibrinogen). We also detected significantly low oxygen saturation, hypercapnia, and severe acidosis in readmitted patients. Radiologic investigations showed that there were severe ARDS with bilateral pneumonic infiltration resistant to medical treatment in 6 out of 11 patients who died (54.5%).
Conclusion: Diffuse pneumonic infiltration related to Covid-19 may develop in asymptomatic cardiac surgery patients with negative RT-PCR test results. Immunologic disorders resulting from ECC, physiologic distress, and anesthesia may activate Covid-19 during the incubation period. We need randomized clinical trials to explain Covid-19 activation in the latent period of the virus, and clinical outcomes in cardiac surgery.
References
American College of Surgeons. 2020. COVID-19: guidance for triage of non-emergent surgical procedures. https:// www.facs.org/covid-19/clinical-guidance/triage
American College of Surgeons. 2020. COVID-19: guidelines for triage of cardiac surgery patients. https://www.facs.org/ covid-19/clinical-guidance/elective-case/cardiac-surgery
Aminian A, Safari S, Razeghian-Jahromi A, Ghorbani M, Delaney CP. 2020. COVID-19 outbreak and surgical practice. Ann Surg. 272(1):27-29.
Bangalore S, Sharma A, Slotwiner A, Yatskar L, Harari R, Shah B, et al. 2020. ST-Segment Elevation in Patients with Covid-19-A. Case Series. N Engl J Med. 382:2478-80.
Barbaro RP, MacLaren G, Boonstra PS, Iwashyna TJ, Slutsky AS, Fan E, et al. 2020. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet. (10):396:1071-1078.
Barkhordari K, Khajavi MR, Bagheri J, Nikkhah S, Shirzad M, Barkhordari S, Kharazmian K, Nosrati M. 2020. Early respiratory outcomes following cardiac surgery in patients with COVID-19. J Card Surg. 35(10):2479-2485.
Bayer A, Dogan OF, Ersoy F, Ersoy U. 2009. The effect of open heart surgery on circulating lymphocytes and lymphocyte subsets in pediatric patients. Turk J Thorac cardiovasc Surg. 17(1):13-17.
Chen N, Zhou M, Dong X, et al. 2020. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 395:507–513.
Chieffo A, Stefanini GG, Price S, et al. 2020. EAPCI position statement on invasive management of acute coronary syndromes during the COVID-19 pandemic. Eur Heart J. 41:1839-851.
Curzen N. 2020. An extended statement by the British Cardiovascular Intervention Society president regarding the COVID-19 pandemic. Interv Cardiol Rev. 15:01.
Delbove A, Foubert A, Mateos F, Guy T, Gousseff M. 2021. High flow nasal cannula oxygenation in COVID-19 related acute respiratory distress syndrome: a safe way to avoid endotracheal intubation? Ther Adv Respir Dis. 15: 1-10.
Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, et al. 2020. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. J Am Coll Cardiol. 12;75(18):2352-2371.
Fang Y, Zhang H, Xie J, et al. 2020. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiol. 19:432.
Giulio G. Montorfano SM, Trabattoni D, et al. 2020. ST-Elevation Myocardial Infarction in Patients with COVID-19: Clinical and Angiographic Outcomes. Circulation. 141:2113-16.
Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. 2020. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 5(7):811-18.
Ing ZC, Zhu HD, Yan XW, Chai WZ, Zhang S. 2020. Recommendations from the Peking Union Medical College Hospital for the management of acute myocardial infarction during the COVID-19 outbreak. Eur Heart J. 41:1791-94.
Keskin G, Khalil, Uysal A. 2021. Should We Postpone Elective Cardiovascular Procedures and Percutaneous Coronary Interventions During the COVID-19 Pandemic? Heart Surg Forum. 24(1): 22-030.
Keskin G, Uysal A, Erturk E, Hafız E, Dogan OF. 2021. Urgent Percutaneous Coronary Artery Intervention and Coronary Artery Bypass Grafting in STEMI Patients with Confirmed COVID-19. Heart Surg Forum. 23;24(3):564-574.
Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. E Clinical Medicine.
McAloon C, Collins A, Hunt K, Barber A, Byrne AW, Butler F, et al. 2020. Incubation period of COVID-19: a rapid systematic review and meta-analysis of observational research. BMJ Open. 16;10(8):e039652.
Niknam J, Rong LQ. 2020. Asymptomatic patients with coronavirus disease and cardiac surgery: When should you operate? J Card Surg. 1–3.
Shi S, Kin B, Bo S. 2020. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. JAMA Cardiol. 5(7):802-810.
Velly L, Gayat E, Quintard H, Weiss E, Jong AD, Cuvillon P, Audibert G. 2020. Guidelines: Anaesthesia in the context of COVID-19 pandemic. Anaesth Crit Care Pain Med. 39(3):395-415.
Welt FGP, Shah PB, Aronow HD, Bortnick AE, Henry TD, Sherwood MW, Young MN, Davidson LJ, Kadavath S, Mahmud E, et al. 2020. American College of Cardiology’s Interventional Council and the Society for Cardiovascular Angiography and Interventions. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from the ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 75:2372-2375.
World Health Organization. 2019. Coronavirus disease (COVID-19) Pandemic. https://www.who.int/emergencies/diseases/ novel-coronavirus-2019.
