COVID Convalescence—A Boon or Bane in Cardiac Surgery?: A “Second Hit” Hypothesis

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Abstract COVID-19 pandemic continues to affect healthcare services. As elective cardiac surgical services resume back to normal, clinicians will encounter COVID-19 recovered patients for cardiac surgery. The hyper-immune pathophysiology of COVID-19 and exposure to inflammation of cardiac surgery, cardiopulmonary bypass, mechanical ventilation, blood transfusion, and perioperative infections could lead to exacerbated responses exemplified by systemic inflammatory response syndrome and cascade to multi-organ dysfunction syndromes. We present a case of a coronary artery disease undergoing off-pump coronary artery bypass surgery after the institutional protocol of two COVID-19 RT-PCR tests were reported negative. Intraoperatively, unexplained hypoxemia was observed, which warranted CPB support to complete the grafting. At multiple attempts of failed weaning, IABP and high inotropes helped to wean. The patient had a stormy postoperative course with low oxygenation, bleeding, low cardiac output syndrome, rhabdomyolysis of lower limb muscles, requiring multiple blood and blood product transfusion, and renal replacement therapy. Despite the corrective measures, severe hyperkalemia, and cardiac arrest ensued. IgG antibodies to the SARS-CoV-2 virus were tested considering the unexplained hypoxemia. A ‘convalescent COVID-19’ patient with ‘first hit’ at primary infection, encountering a ‘second hit’ of surgery and perioperative insults might result in a hyper-immune response. This ‘second hit’ hypothesis should be considered when COVID-19 convalescent (COVID-19 disease symptomatic or asymptomatic) patients undergo cardiac surgery and present with unusual complications.