COVID-19 in Cardiac Surgery: A Proposed Prioritization Framework
As the SARS-CoV-2 pandemic has been reaching unprecedented highs across the US, hospitals have become overwhelmed with patients treated for COVID-19. Hospital resources (beds, equipment, and personnel) have been allocated to control this pandemic and resources for cardiac surgical patients are now limited. Regulatory authorities at regional and national levels have requested that elective cases be cancelled until further notice. The Society of Thoracic Surgeons has added a temporary code for COVID-19 patients to prospectively assess the impact of the disease to cardiac surgery patients and they have excluded these patients from surgeon and program reporting, presumably because of the expected increased morbidity and mortality (1).
The peak of this pandemic has not been reached in the United States, and it is difficult to foresee when hospital operations will resume in a regular manner. Surgeons and patients are not accustomed to waiting long periods of time for their surgery compared to other countries. The median waiting time for a coronary artery bypass grafting (CABG) patient is six days, while in other countries, such as Canada, the UK, and Germany, median waiting time may be as high as 206 days (2). We are now called to adapt in an expeditious manner and prioritize patients, both in urgent as well as elective settings, based on this new reality of very limited resources. The American College of Surgeons has provided some guidance in triaging elective patients in various specialties, but has not addressed cardiac surgery specifically (3).
In the first weeks of imposed measures, the authors’ cardiac surgery department initiated discussions in a multidisciplinary approach on how to alter management of elective and urgent cases. In this report, the authors present data that helps identify the added risks associated with the COVID-19 disease, but also the risk imposed to patients waiting longer for cardiac surgery than they would otherwise have. A prioritization framework based on already published risks scores and guidelines for appropriate use are described as an added tool to supplement thorough patient assessment and sound clinical judgment.