Committee Recommendations for Resuming Cardiac Surgery Activity in the SARS-CoV-2 Era: Guidance From an International Cardiac Surgery Consortium

 [bib_ref] Precautions and procedures for coronary and structural cardiac interventions during the COVID-19..., Wood [/bib_ref] [bib_ref] Triage considerations for patients referred for structural heart disease intervention during the..., Shah [/bib_ref] [bib_ref] Adult cardiac surgery during the COVID-19 pandemic: a tiered patient triage guidance..., Haft [/bib_ref] [bib_ref] Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from..., Hassan [/bib_ref] [bib_ref] ASE statement on protection of patients and echocardiography service providers during the..., Kirkpatrick [/bib_ref] [bib_ref] Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography..., Choi [/bib_ref] [fig_ref] 1: The cardiovascular service line, including cardiac surgery, should be among the first... [/fig_ref] 

## A. guidance on restarting cardiac surgery activity
Class I Recommendations The incremental mortality associated with suspending all elective cardiac surgery within a wide geographic region for 6 to 8 weeks may be estimated from studies of health care systems where surgery is routinely deferred for many weeks because of lack of capacity. For example, in 5864 patients waiting for elective or urgent coronary bypass surgery in Sweden, the risk of death increased by 11% per month. [bib_ref] Mortality on the waiting list for coronary artery bypass grafting: incidence and..., Rexius [/bib_ref] A New Zealand study demonstrated significant incremental operative mortality in the nearly 20% of patients readmitted with acute coronary syndromes while waiting for bypass surgery. 14 A coordinated approach with cardiology services, including invasive cardiology is essential, because these are an integral part of the cardiovascular patient evaluation and management. Supporting references: 13, 14.
2. Triggers and contingency plans for modifying cardiac service line activity in response to government regulations, hospital capacity, and disease burden should be agreed upon and clearly communicated with clinicians to minimize adverse events due to abrupt changes in clinical practice. (Level of evidence: C)
A clear response framework, such as the one outlined in [fig_ref] Table 2: Guidance for Adapting Cardiac Surgery Care Delivery in Response to Government Requirements,... [/fig_ref] , 4,6-10 enables the cardiac service line to adapt more safely and effectively to changes in governmental requirements, critical care capacity, and prevalence of disease in the community. If advisories conflict, federal and state mandates take priority over hospital policy and local assessment of disease burden. Cardiac specialists triaging patients within a resource allocation of critical care and floor beds, operating room, and outpatient time, may allow a more efficient response to evolving constraints than attempting to redefine which patients should be prioritized at each stage. Supporting references: 4-6.
3. Reduced cardiac critical care capacity mandates safe and effective triage of elective cardiac surgery patients. Such triage should be led by specialists in cardiac surgery, using formal guidelines as agreed by the heart team [fig_ref] Table 2: Guidance for Adapting Cardiac Surgery Care Delivery in Response to Government Requirements,... [/fig_ref]. (Level of evidence: C)
The incremental mortality in patients whose cardiac surgery is deferred during this pandemic may be partially mitigated by effective triage with careful attention to risk factors such as symptoms, ventricular dysfunction, arrhythmias, and age, considering percutaneous coronary or valve intervention and optimizing medical therapy with frequent follow-up. For example, risk factors for death while waiting for coronary bypass included left main stem disease, reduced ejection fraction, unstable angina, and atrial fibrillation. [bib_ref] Mortality on the waiting list for coronary artery bypass grafting: incidence and..., Rexius [/bib_ref] Untreated aortic stenosis is associated with higher mortality. In a recent analysis of 823 patients waiting an average of 3 weeks for transcatheter or surgical aortic valve replacement, the mortality was 4% at 1 month in both groups. [bib_ref] Mortality while waiting for aortic valve replacement, Malaisrie [/bib_ref] Patients who died were significantly older and more likely to have left ventricular dysfunction or New York Heart Association Functional Classification II or IV symptoms.
Involving cardiac surgeons early in the development of specific guidance and triage committees is essential, particularly when cancer, trauma, and other urgent care needs must be balanced, because the methods routinely used to allocate resources and prioritize patients across multiple specialties are aimed at optimizing normal daily resource use and are not designed to balance risks of deferring surgery. Very complex and high-risk cases should be performed when critical care capacity is adequate with resources for extended support, whereas if those resources are scarce the utility and ethics may be less justifiable. Supporting references: 4-6, 12-15.
4. Clear, accurate, and timely information on the availability of cardiovascular services and how to access them should be provided to referring physicians, patients, and the community. (Level of evidence: C)
The substantial decrease in elective and emergency cardiovascular presentations to outpatients and the emergency departments observed in most centers can be attributed, firstly, to reduced access to primary care offices, and secondly, to necessary triage by emergency responders, and thirdly, to high levels of patient concern about visiting hospitals. Initial reports suggest this may account for significant incremental non-COVID cardiac mortality. [bib_ref] Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern..., De Fillippo [/bib_ref] Consistent, accurate, and effective communication with primary care and cardiology providers is essential to ensure that their approach is aligned with the availability of inpatient cardiac care and that patient concerns are allayed. This may usefully be supported by direct patient messaging, without which news stories in the lay media provide the sole information for patients making decisions about their health care options. Supporting reference: 16.
Class IIa Recommendations 1. A regional response is a reasonable strategy to ensure appropriate delivery of elective cardiac surgery. (Level of evidence: C)
A regional response entails a coordinated effort to increase and optimize critical care capacity, expertise, and personnel between hospitals, preserving the ability of selected centers to provide cardiac surgery services on behalf of an expanded population while other centers divert resources to managing SARS-CoV-2. In Italy and the United Kingdom, this type of regional response has enabled continuous provision of cardiac surgery at selected high-volume centers and coordination of effort and experience for extracorporeal membrane oxygenation (ECMO) support. [bib_ref] Planning and provision of ECMO services for severe ARDS during the COVID-19..., Ramanathan [/bib_ref] In comparison, disaster planning in the United States is primarily organized at an individual hospital level, with governmental agencies issuing 2. It is reasonable to substitute a less-invasive approach when insufficient hospital capacity precludes planned cardiac surgery, and when patient preference informed by a shared-decision-making approach with the Heart Team also supports the balance of risks. (Level of evidence: C)
Most low-risk elective patients may safely wait up to 4 weeks for planned cardiac surgery. [bib_ref] Adult cardiac surgery during the COVID-19 pandemic: a tiered patient triage guidance..., Haft [/bib_ref] [bib_ref] Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from..., Hassan [/bib_ref] However, mortality and complications may occur in apparently low-risk patients. [bib_ref] Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from..., Hassan [/bib_ref] If urgent surgery is not possible, any clinical deterioration indicating a need for more urgent intervention should trigger a discussion with the heart team to review alternative therapeutic strategies, including surgery at another peer center, transcatheter valve intervention, or percutaneous coronary intervention, or a combination of these. [bib_ref] ASE statement on protection of patients and echocardiography service providers during the..., Kirkpatrick [/bib_ref] Supporting references: 4-6, 10.

## B. guidance on adapting cardiac surgery care
Class I Recommendations 1. All cardiac surgery patients should be screened preoperatively for COVID-19 and strong consideration be given to deferring care or using other care modalities for patients that test positive. (Level of evidence: C)
All cardiac surgery patients should be tested 48 hours preoperatively for COVID-19, until the prevalence of asymptomatic community spread is minimal. Anecdotal reports indicate that COVID-19 infection in the perioperative period is associated with significant morbidity and mortality, so cardiac surgery should be deferred where possible until the patient tests negative. In a patient with active COVID-19 infection who cannot safely be deferred, percutaneous and transcatheter therapies may be the safer option. Lung and heart transplant donors and recipients should be screened and no transplants performed in positive patients. An important additional rationale for screening cardiac surgery patients for SARS-CoV-2 is the risk posed to health care workers during intubation, extubation, disconnection of the ventilator, and bronchoscopy from aerosolization.should therefore be dedicated to the care of cardiac surgery patients with SARS-CoV-2. Immunocompromised patients, including transplant recipients, should be cohorted in the intensive care unit area most distant from this. Epidemiology and infection protocols should guide designation of clean and contaminated space in the COVID area [fig_ref] 1: Remote working and telemedicine should be used to provide close and convenient... [/fig_ref]. Limitations on visitors, in-room rounding, and care pathways should be redesigned to minimize traffic through the COVID area. Careful and frequent education of nursing, intensivist staff, and consultant staff in use of PPE, virtual rounding, and dedicated teams for high-risk procedures, such as intubations, will minimize the risk of cross-infection. At the time of this writing, more than 19% of patients infected with SARS-CoV2 and 60 deaths in Italy alone were health care workers. Intubation and extubation, disconnection from the ventilator, bronchoscopy, and tracheostomy expose the health care team to the greatest risk of viral transmission. This was recognized at a relatively early stage in a joint position statement from the American Society of Anesthesiologists, which recommended full-powered air-purifying respirators for induction and extubation of patients in endemic areas.There are noticeable disparities between PPE protocols between different centers in different regions and countries.The American College of Surgeons recommends N95 respirators, particularly when operating on patients with confirmed or suspected COVID-19.Thus, for individuals at highest risk of exposure at institutions that are unable to provide N95 masks to all members of the operating team, the American College of Surgeons recommends that all surgeons and other personnel who are not wearing N95s leave the operating room during intubation, extubation, and other necessary adjunct procedures that can generate aerosolized small particles.Team simulations to practice in advance of these common clinical scenarios may improve safety. Procedural aspects of the procedures should be modified in patients with SARS CoV-2 to decrease aerosolization, including using lower coagulation settings for electrocautery, avoiding endoscopic vein harvesting to minimize aerosolization with CO 2 insufflation and avoiding ventilator tubing disconnection. Supporting references: Class III Recommendation 1. It may be harmful to discharge postoperative cardiac surgery patients to nursing facilities where increased prevalence of SARS-CoV-2 infection and mortality has been observed. (Level of evidence: C)
The prevalence of SARS-CoV-2 and associated mortality in long-term community nursing facilities in the United States was especially high, and it is therefore not advisable to discharge postoperative patients to facilities where increased risk of SARS-CoV-2 remains a concern. Where institutions have relied on these facilities, it will be necessary to develop new discharge strategies to avoid the risk of community infection after hospital discharge. These should include extended hospital admission to maximize independence and planning for skilled home nursing support. Educating all patients and family members preoperatively in social distancing, use of PPE, and recognizing when to seek medical advice is essential.

## C. guidance on managing cardiac surgery research and education
Class I Recommendations Telemedicine for outpatient visits and remote working, including video conferencing, is a potentially helpful practice change to emerge from the pandemic response. In the United States, many states and health care payers approved payment for clinical consultations and followup conducted by video (although not phone only). Effective, early roll-out of secure, patient confidentialitycompliant video consultations will help mitigate the reluctance of patients with advanced cardiac morbidity to seek appropriate care and allow closer follow-up of patients deferred for surgery. For postoperative patients, community primary care or cardiology practices may be willing to provide in-person visits where suture removal and incision checks can be performed. Hospital workflow may also use remote working in the form of video rounds and conferences that facilitate team-based decision making, education, and administrative meetings while social distancing.

## Class iia recommendation
1. It is reasonable to revise resident rotations to address reduced operative experience, and support research programs halted or suspended during the pandemic response. (Level of evidence: C)
Educational activity was suspended or reduced in 50% of cardiac surgery centers that responded to a survey that also showed a reduction of 50% to 75% in operative cases.This may have the greatest effect in countries such as the United States where the total time spent in cardiac surgery training may be as little as 12 months and could explain why half of centers were still allowing residents to operate, even at the expense of prolonging surgery times. Research activity was similarly impacted, which may hamper efforts to obtain early data and underlines the need for real-time data collection and analysis that could inform practice in real time. The reallocation of funding activity and journal focus to research on SARS-CoV-2 may divert resources from equally impactful cardiac research. Coordinated follow-up of all cardiac surgery patients to quantify the incidence and outcomes of the COVID-19 infection and the outcomes related to deferred surgery in this population is essential to inform future policy and individual consent.

# Conclusions
The above practice recommendations provide an expertbased framework for restarting cardiac surgery in the outpatient and inpatient settings in a health care environment characterized by a low-grade long-term prevalence of SARS-CoV-2. Although the applicability of these recommendations may vary according to local context and as new information becomes available, we anticipate that this guidance document will assist centers in managing the 2 simultaneous threats-COVID-19 and death/ morbidity in patients awaiting cardiac surgery-that institutions providing cardiac surgical care must now constantly balance.
[fig] 1: Remote working and telemedicine should be used to provide close and convenient patient follow-up and minimize exposure of patients and health care workers to infection. (Level of evidence: C) [/fig]
[table] Table 2: Guidance for Adapting Cardiac Surgery Care Delivery in Response to Government Requirements, Hospital Capacity, and Infectious Disease Burden 4-6,10 [/table]