Cardiac Surgery in Australia During the COVID-19 Global Pandemic

Abstract

In this issue of Heart, Lung and Circulation, McNamara and colleagues [[1]McNamara N. Robinson B. Bannon P. The impact of COVID-19 on the provision of adult cardiac surgery at a dedicated COVID hospital in Australia.Heart Lung Circ. 2021; 30: 1841-1845Abstract Full Text Full Text PDF Scopus (2) Google Scholar] report a 21% reduction in the cardiac surgical caseload from a single centre during the first Australian wave of the COVID-19 pandemic from March to June 2020. Globally, elective cardiac surgery ground to a halt and as the pandemic rapidly escalated, centres in Australia and New Zealand were able to benefit from the collective experiences of those in the United Kingdom (UK) [[2]Hussain A. Balmforth D. Yates M. Lopez-Marco A. Rathwell C. Lambourne J. et al.The Pan London Emergency Cardiac Surgery service: coordinating a response to the COVID-19 pandemic.J Card Surg. 2020; 35: 1563-1569Crossref PubMed Scopus (19) Google Scholar], Canada [[3]Hassan A. Arora R.C. Adams C. Bouchard D. Cook R. Gunning D. et al.Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from the Canadian Society of Cardiac Surgeons.Can J Cardiol. 2020; 36: 952-955Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar], Italy [[4]Bonalumi G. di Mauro M. Garatti A. Barili F. Gerosa G. Parolari A. et al.The COVID-19 outbreak and its impact on hospitals in Italy: the model of cardiac surgery.Eur J Cardiothorac Surg. 2020; 57: 1025-1028Crossref PubMed Scopus (55) Google Scholar] and the United States [[5]Worthington T. Khoynezhad A. A Perspective from Los Angeles of COVID-19 effect and impact on cardiac surgery.J Card Surg. 2021; 36: 1665-1667Crossref PubMed Scopus (1) Google Scholar,[6]George I. Salna M. Kobsa S. Deroo S. Kriegel J. Blitzer D. et al.The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a center at the epicenter.J Thorac Cardiovasc Surg. 2020; 160: 937-947.e2Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. A year on, we now have the benefit of not only understanding the immediate effect of pandemic surge but also the implications of elective surgery cancellations in the context of revising the definition of cardiac surgical urgency. As the pandemic continues to unfold, it is essential that we emphasise the importance of the acute benefits of cardiac surgery, that in contrast to many other elective surgeries, disproportionately saves lives. In March 2020, a global survey of cardiac surgery centres participating in the Randomization of Single vs Multiple Arterial Grafts (ROMA) trial [[7]Gaudino M. Alexander J.H. Bakaeen F.G. Ballman K. Barili F. Calafiore A.M. et al.Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.Eur J Cardiothorac Surg. 2017; 52: 1031-1040Crossref PubMed Google Scholar] reported a greater than 50% reduction in intensive care unit (ICU) bed availability for cardiac surgery and a median reduction in cardiac surgery case volume of 50% to 75% [[8]Gaudino M. Chikwe J. Hameed I. Robinson N.B. Fremes S.E. Ruel M. Response of cardiac surgery units to COVID-19: an internationally-based quantitative survey.Circulation. 2020; 142: 300-302Crossref PubMed Scopus (54) Google Scholar]. In London, a pan-regional service plan was enacted that funnelled emergency cardiac surgery cases to either the Barts Heart Centre or to Harefield Hospital [[2]Hussain A. Balmforth D. Yates M. Lopez-Marco A. Rathwell C. Lambourne J. et al.The Pan London Emergency Cardiac Surgery service: coordinating a response to the COVID-19 pandemic.J Card Surg. 2020; 35: 1563-1569Crossref PubMed Scopus (19) Google Scholar] and there was an 83% reduction in index cardiac surgical cases across the UK from March to May 2020 [[9]Mohamed Abdel Shafi A. Hewage S. Harky A. The impact of COVID-19 on the provision of cardiac surgical services.J Card Surg. 2020; 35: 1295-1297Crossref PubMed Scopus (34) Google Scholar]. New York (NY) City was the global epicentre of the pandemic at this time and there was a 92% reduction in cardiac surgical cases compared to 2019 at the NY Presbyterian Hospital where surgeons led the development and dissemination of revised cardiac surgical priority definitions [[6]George I. Salna M. Kobsa S. Deroo S. Kriegel J. Blitzer D. et al.The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a center at the epicenter.J Thorac Cardiovasc Surg. 2020; 160: 937-947.e2Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Concurrently, the West Coast of the USA had a 62% decline in emergency department presentations, a 35% decline in total hospitalisations and complete cessation of surgery that was not considered an emergency procedure. The estimated impact of these changes equated to a predicted loss of almost US$15 billion by the end of 2020 in California alone [[5]Worthington T. Khoynezhad A. A Perspective from Los Angeles of COVID-19 effect and impact on cardiac surgery.J Card Surg. 2021; 36: 1665-1667Crossref PubMed Scopus (1) Google Scholar]. Cardiac surgery is a resource intensive specialty heavily dependent on ICU bed availability. The approach to maximising the availability of ICU beds to accommodate patients needing cardiac surgery during the pandemic has varied according to the structure of the health service in which ICU beds are situated. Most reports describe the transfer of emergency cases to centres with dedicated ICU bed availability for the specific purpose of managing cardiac surgery patients, in recognition of the fact that there is always a relatively consistent proportion of patients that meet the need for urgent surgery, which could readily escalate to an emergency. The NY Presbyterian Hospital's revised surgical status priorities [[6]George I. Salna M. Kobsa S. Deroo S. Kriegel J. Blitzer D. et al.The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a center at the epicenter.J Thorac Cardiovasc Surg. 2020; 160: 937-947.e2Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] were based on a history of 40% of cases being urgent. This group reclassified those able to wait for a month or more as elective, those who could wait at home but needed surgery within 3–4 weeks as semi-urgent, high-risk inpatients as urgent and emergent cases requiring immediate intervention. The approach in Canada and the UK was similar. There were unprecedented multidisciplinary changes in health service delivery in response to the influx of COVID positive patients requiring hospitalisation and critical care. Scaled staff redeployment for medical and nursing teams was a key feature of strategies to accommodate surge demand for ICU beds and potential increases in urgent cases as a consequence of the cardiopulmonary sequelae of COVID-19. In the UK, dedicated cardiac surgical ICU teams were redeployed to relieve general ICU teams. Of the 20 cardiac surgical units in Italy, 16 closed and all urgent and emergency cases were sent to the remaining four that were staffed by shared surgical teams [[4]Bonalumi G. di Mauro M. Garatti A. Barili F. Gerosa G. Parolari A. et al.The COVID-19 outbreak and its impact on hospitals in Italy: the model of cardiac surgery.Eur J Cardiothorac Surg. 2020; 57: 1025-1028Crossref PubMed Scopus (55) Google Scholar]. Canadian surgeons were provided with a series of guiding statements to triage cases and teams according to waiting list length, urgency and ICU bed demand [[3]Hassan A. Arora R.C. Adams C. Bouchard D. Cook R. Gunning D. et al.Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from the Canadian Society of Cardiac Surgeons.Can J Cardiol. 2020; 36: 952-955Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. In the peak of the initial crisis as clinicians responded to the change in demand, they too contracted the virus. Within 6 months of the first case being detected more than 7,000 health care workers globally had died, 1,500 of whom were nurses [[10]Wynne R. Davidson P.M. Duffield C. Jackson D. Ferguson C. Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper.J Clin Nurs. 2021; : 1-10https://doi.org/10.1111/jocn.15916Crossref Scopus (11) Google Scholar]. Medical staff and indeed cardiac surgeons were not exempt from risk, volunteering in some instances to cover critical care nursing roles [[11]Fudulu D.P. Angelini G.D. Cardiac surgery in the time of the coronavirus.J Card Surg. 2020; 35: 1177-1179Crossref PubMed Scopus (17) Google Scholar]. Not surprisingly, emerging evidence indicates a significant increase in the proportion of patients considered urgent and an increased risk of mortality for COVID-19 positive patients following cardiac surgery [12Lopez-Marco A. Harky A. Verdichizzo D. Hope E. Rosser B. McPherson I. et al.Early experience of aortic surgery during the COVID-19 pandemic in the UK: a multicentre study.J Card Surg. 2021; 36: 848-856Crossref PubMed Scopus (6) Google Scholar, 13Lazaros G. Oikonomou E. Theofilis P. Theodoropoulou A. Triantafyllou K. Charitos C. et al.The impact of COVID-19 pandemic on adult cardiac surgery procedures.Hellenic J Cardiol. 2021; 62: 231-233Crossref PubMed Scopus (15) Google Scholar, 14Keskin G. Khalil E. Uysal A. Should we postpone elective cardiovascular procedures and percutaneous coronary interventions during the COVID-19 pandemic?.Heart Surg Forum. 2021; 24: E022-E30Crossref PubMed Scopus (4) Google Scholar, 15Farrington W.J. Mack C.A. Karas M.G. Ivascu N.S. Robinson N.B. Iannacone E. et al.A perspective from New York of COVID 19: effect and impact on cardiac surgery.J Card Surg. 2021; 36: 1668-1671Crossref PubMed Scopus (3) Google Scholar, 16Casanova J. Pissarra D. Costa R. Salgueiro E. Pinho P. Cardiothoracic surgery during the Covid-19 pandemic: perioperative care, safety, and surgical results.J Card Surg. 2020; 35: 2605-2610Crossref PubMed Scopus (4) Google Scholar, 17Barkhordari K. Khajavi M.R. Bagheri J. Nikkhah S. Shirzad M. Barkhordari S. et al.Early respiratory outcomes following cardiac surgery in patients with COVID-19.J Card Surg. 2020; 35: 2479-2485Crossref PubMed Scopus (17) Google Scholar]. The COVIDSurg Collaborative, reported 20.8% mortality in 207 COVID-19 positive patients from 13 countries [[18]Cardiothoracic Interdisciplinary Research N. Collaborative C.O. Early outcomes and complications following cardiac surgery in patients testing positive for coronavirus disease 2019: an international cohort study.J Thorac Cardiovasc Surg. 2021; 162: e355-e372Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] operated on between March and June, 2020. In a retrospective propensity matched cohort from a similar time frame, an increased mortality persisted, and the mortality associated with a postoperative COVID-19 diagnosis was significantly higher than that in patients operated after suffering COVID-19 preoperatively [[19]Sanders J. Akowuah E. Cooper J. Kirmani B.H. Kanani M. Acharya M. et al.Cardiac surgery outcome during the COVID-19 pandemic: a retrospective review of the early experience in nine UK centres.J Cardiothorac Surg. 2021; 16: 43Crossref PubMed Scopus (22) Google Scholar]. Fortunately, the Australian experience was in stark contrast to that of our international counterparts. Our initial lockdown in 2020 was relatively short-lived and, until recently, there had been relatively low numbers of COVID-19 cases. McNamara and colleagues noted no change in surgical acuity and an overall reduction of only 21% in total caseload when 2020 cases during the 4-month period were compared to those in 2019 at their COVID-19 nominated centre [[1]McNamara N. Robinson B. Bannon P. The impact of COVID-19 on the provision of adult cardiac surgery at a dedicated COVID hospital in Australia.Heart Lung Circ. 2021; 30: 1841-1845Abstract Full Text Full Text PDF Scopus (2) Google Scholar]. The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database has 56 contributing centres from Australia, complemented by the addition of data from Auckland since 2019, with most contributing cases taking place in New South Wales (NSW) and Victoria—the states most affected by COVID-19. In the last 5 years (2016–2020) total case numbers within the database have steadily increased as new centres joined and so has the proportion of patients requiring urgent surgery across Australia (Table 1). Monthly trends of elective and urgent cardiac surgery operations performed over the 5-year period are shown in Figures 1 and 2.Table 1Patient characteristics.Patient Characteristic20162017201820192020P-valueNumber12,90517.913,42618.714,34019.915,65521.815,64321.7Age (years)65.412.965.512.965.612.865.313.065.312.80.12Male9,55374.09,95074.110,65874.311,56073.811,65574.50.71Aboriginal and, or Torres Strait Islander4473.54573.44333.04483.14713.20.13Preoperative hospital length of stay1.00.0, 4.01.00.0, 4.01.00.0, 4.01.00.0, 4.01.01.0, 4.00.26Postoperative length of stay7.06, 11.07.06, 11.07.06, 11.07.06, 11.07.06, 11.00.18Risk (AusScore Total)4.02, 6.04.02, 6.04.02, 6.04.02, 7.04.0aDenotes point of significant difference.2, 7.0>0.001Operative Status>0.001 Elective9,08170.49,11167.910,02269.910,35266.19,79962.6 Urgent3,21124.93,64127.13,67225.64,47628.65,10132.6aDenotes point of significant difference. Emergent/Salvage6044.76735.06434.58275.27434.8Procedure CABG8,29464.3aDenotes point of significant difference.8,49763.38,75261.09,58161.29,58161.2>0.001 Aortic valve surgery3,06723.83,13923.43,33123.23,40721.83,39621.7aDenotes point of significant difference.>0.001 Mitral valve surgery9177.19467.01,0307.21,1307.21,1597.40.79 Aortic dissection960.7aDenotes point of significant difference.2702.02501.73352.13162.0>0.001 Other1,62412.61,98214.82,32916.22,57016.42,67517.1>0.001Values shown are number/percentage, mean/standard deviation or median/quartiles.Source: ANZSCTS Cardiac Surgery Database (MH HREC QA Approval 2,021,098).Abbreviations: CABG, coronary artery bypass graft/s.a Denotes point of significant difference. Open table in a new tab Figure 2Urgent case load 2016 to 2020.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Values shown are number/percentage, mean/standard deviation or median/quartiles. Source: ANZSCTS Cardiac Surgery Database (MH HREC QA Approval 2,021,098). Abbreviations: CABG, coronary artery bypass graft/s. In response to elective cancellations and the creation of dedicated COVID-19 hospitals, some centres were able to redirect public patients to private centres (n=386) from March (n=25, 4.4%) that peaked in April (n=76, 10.1%) and continued to a lesser extent until December. The total national caseload numbers in 2020 (n=14,900) were consistent with 2019 (n=14,828). However, the proportion of patients requiring urgent surgery in 2020 (n=5,101, 34.2%) was higher than in 2019 (n=4,476, 30.2%; χ2 55.7 (1), p<0.001). When monthly cases numbers were compared across the 2 years (Figures 3 and 4), there was a reduction in elective caseload from April to December, except for June, and a significant increase in the proportion of urgent monthly cases from June that persisted and peaked in December.Figure 4Proportion of monthly elective and urgent case load in 2019 and 2020.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our ability to contain COVID-19 in 2020 provided an opportunity for our health care system to prepare for a more sustained pandemic response. As this Editorial was being written, NSW reported record numbers of COVID-19 cases and implemented ICU pandemic escalation plans to increase bed capacity from their baseline 592 staffed beds [[20]Agency for Clinical InnovationNSW adult intensive care services pandemic response planning 2021.https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/592284/Adult-IC-pandemic-response-planning.pdfDate accessed: September 8, 2021Google Scholar] to the 947 beds which modelling suggests would be needed by November 2021 [[21]NSW Ministry of HealthIntensive Care capacity 2021.https://www.nsw.gov.au/sites/default/files/2021-09/Intensive_Care_Capacity_0.pdfDate accessed: September 8, 2021Google Scholar]. A competent and flexible workforce underpins the capacity for a pandemic surge response and subsequent recovery [[22]Wynne R. Conway A. Davidson P.M. Ensuring COVID-related innovation is sustained.J Adv Nurs. 2021; 77: e4-e6Crossref PubMed Scopus (5) Google Scholar]. The impact of deferring elective surgery in early 2020 appears to have had a ‘knock on’ effect, as evidenced by the sustained increase in urgent surgical cases for the remainder of the year. It has been argued that nothing in cardiac surgery is truly elective, as operations performed in the absence of symptoms or physiological derangement are a prophylactic or prognostic measure [[23]Rajagopal K. Commentary: implications of coronavirus disease 2019 (COVID-19) for cardiac surgery: priorities and decisions.J Thorac Cardiovasc Surg. 2020; 160: 951-952Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. Revised international surgical priority classifications do not appear to have had a detrimental impact on patients waiting for surgery to date [[24]Harky A. Harrington D. Nawaytou O. Othman A. Fowler C. Owens G. et al.COVID-19 and cardiac surgery: a perspective from United Kingdom.J Card Surg. 2021; 36: 1649-1658Crossref PubMed Scopus (17) Google Scholar] but previous research shows that rates of mortality increase in systems where surgery is routinely deferred because of limited capacity [[25]Seddon M.E. French J.K. Amos D.J. Ramanathan K. McLaughlin S.C. White H.D. Waiting times and prioritization for coronary artery bypass surgery in New Zealand.Heart. 1999; 81: 586-592Crossref PubMed Scopus (81) Google Scholar]. Intentionally decreasing elective cardiac surgery is one mechanism in the strategy to accommodate increased ICU and hospital bed demand but at what cost to patients, specialist staff and the health care system? Optimal vaccination targets within the general community are seen to be the remedy to balance competing demands within our health care system. As we race to achieve adequate levels of immunity in the community, the assumption that COVID-19 care is more effective at saving lives than cardiac surgery waits to be tested. The Impact of COVID-19 on the Provision of Adult Cardiac Surgery at a Dedicated COVID Hospital in AustraliaHeart, Lung and CirculationVol. 30Issue 12PreviewInternationally, the response to the COVID-19 pandemic has resulted in fewer cardiac surgical procedures being performed and an increase in the proportion of non-elective cases. To date there has been no study examining the impact of COVID-19 on the provision of cardiac surgery in Australia. Full-Text PDF