A retrospective observational study of patients undergoing cardiac surgery in the UK between March and April 2020, at the height of the first wave of the COVID-19 pandemic, has found that those who were diagnosed with COVID-19 at the time of surgery had greater risk of death than those without COVID-19.
Published in the Journal of Cardiothoracic Surgery, the study authored by Julie Sanders (Barts Health NHS Trust, London, UK) and colleagues investigated cardiac surgery outcomes during the early phase of the pandemic, looking at all adult patients undergoing cardiac surgery between 1 March and 30 April 2020 across nine UK centres.
In total 755 patients underwent cardiothoracic surgery. Of these, 53 (7%) had COVID-19. Compared to those without COVID-19, Sanders et al report, those with COVID-19 had increased mortality (24.5% v 3.5%, p<0.0001) and longer post-operative stay (11 days vs. six days, p=0.001), both of which remained significant after propensity score matching.
Additionally they found that patients with a preoperative COVID-19 diagnosis recovered in a similar way to non-COVID-19 patients. However, those with a postoperative COVID-19 diagnosis remained in hospital for an additional five days (12 days vs. seven days, p=0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% vs 0%, p=0.005).
Examining the findings, Sanders et al write that the pre- and post-surgery diagnosis divide has been recently reported in the COVIDSurg study, a large global cohort of patients undergoing elective and emergency surgery during the pandemic, findings from which were published in The Lancet. They speculate that surgery may accelerate the progression of COVID-19 through an altered immune response, thus progressing the disease process in those preoperatively incubating COVID-19. Sanders et al add: “Equally, although the presence of pre-surgery COVID-19 may have led to the postponement of some surgery until negative COVID-19 swab results were obtained (especially for elective surgery patients), it is likely that if a patient was diagnosed pre-operatively, then operative processes, timing and treatment plans could be altered accordingly to reduce overall risk.”
These findings have led the study’s authors to conclude that in order to mitigate against the risks of COVID-19—in particular the post-operative burden—robust and effective pre-surgery diagnosis protocols are needed, alongside effective strategies to maintain a COVID-19 free environment.
In addition they call for the establishment of dedicated cardiac surgery ‘hubs and spoke systems’ similar to that implemented in Italy, to facilitate COVID-19-free environments for the treatment of patients.
They add: “This is especially important as we identified a 52% reduction in cardiac surgery during this period, which is similar to that reported elsewhere. This reduction of surgery, specifically the halting of elective surgery, will ultimately have a detrimental effect both on individuals’ waiting times (and their subsequent health deterioration) and healthcare organisations’ ability to manage the accumulation of patients, especially if subsequent COVID-19 peaks occur.”
Summing up the findings of the study, Sanders et al write: “Our study, thought to be the largest cohort study exploring cardiac surgery outcomes during a pandemic, identified that patients with COVID-19 had more than five times greater odds of dying than those without COVID-19. Those with a preoperative diagnosis of COVID-19 appeared to recover from surgery in a similar manner to non-COVID-19 patients, but that the mortality burden of COVID-19 appears to particularly impact those diagnosed after surgery.“
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