Safety for All: Coronavirus Disease 2019 Pandemic and Cardiac Surgery: a Roadmap to ‘Phase’ 2
The coronavirus disease 2019 (COVID-19) pandemic, caused by SARS-CoV-2, is affecting several areas of the world with different degrees of severity. Italy, in particular its northern regions, which include Lombardy, Piedmont, Veneto and Emilia Romagna, has been the first European country affected by COVID-19.
After a series of attempts to control the spread of the infection with local area lockdowns, the prevalence of the infection rose significantly and led to a nationwide lockdown on 9 March 2020.
The COVID-19 pandemic has led the emergency task forces of the 20 Italian regions to reallocate intensive care unit resources, to cancel elective surgical procedures and to allocate intensive care unit beds usually dedicated to cardiac, neurosurgery and some coronary care patients to the care of patients with COVID-19. Two models have been used to allocate cardiac surgical services. In Lombardy, the Italian region most severely affected by the epidemic, a ‘hub and spoke’ approach has been implemented. Four of the 20 cardiac surgical units have continued their routine activity (hubs), and the remaining 16 units (spokes) stopped cardiac surgical activity and their resources were reallocated to the care of patients with COVID-19. All the emergency and urgent cardiac surgical cases, as well as patients on the waiting lists requiring treatment within 60 days, were diverted to the 4 hub units. In Veneto, the 5 cardiac surgical units remained operational but were allowed to treat only urgent cases.
Since the second week of April, the COVID-19 pandemic has moved towards a more controlled phase of viral spread. The second phase (phase 2) of the treatment of COVID-19 is expected to begin 4 May 2020. In addition to the mortality and morbidity caused directly by infection with SARS-CoV-2, the reorganization of acute services has inevitably led to a reduction in the examination and treatment of several non-COVID clinical conditions in the areas of cancer and cardiovascular disease. In addition, some patients are receiving ‘second best’ treatment, such as coronary artery stenting and transcatheter aortic valve implantation, because surgical treatment is not available. These changes may have led to sizeable collateral damage, including increased mortality and morbidity from non-COVID conditions. A recent report from the British Office of National Statistics estimated that up to one-third of the extra deaths recorded this year compared to previous years are from causes other than COVID-19 [5].
Health care communities need to develop a strategy to restart non-COVID medical and surgical care. To achieve this goal safely, they need to develop a ‘roadmap’. We describe a possible way to start phase 2 in cardiac surgery. Our strategy is based on achieving the following 2 goals: (i) given the geographical heterogeneity of the epidemic, assessing the level of spread and severity in any given area and (ii) developing a COVID-free pathway to mitigate the risk of nosocomial infection. Because it is beyond the scope of this manuscript to cover all eventualities in detail, our goal is to provide general principles to inform local strategy when approaching phase 2.
