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Commentary: Adapting the practice of congenital heart surgery to the coronavirus disease 2019 (COVID-19) pandemic

  • Emile Bacha
    Correspondence
    Address for reprints: Emile Bacha, MD, Pediatric and Congenital Cardiac Surgery, Morgan Stanley Children's Hospital NewYork-Presbyterian/Columbia University Medical Center, 3959 Broadway, New York, NY 10032.
    Affiliations
    Pediatric and Congenital Cardiac Surgery, Morgan Stanley Children's Hospital NewYork-Presbyterian/Columbia University Medical Center, New York, NY
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Open ArchivePublished:June 23, 2020DOI:https://doi.org/10.1016/j.jtcvs.2020.06.013
      As the COVID-19 pandemic ravages some countries, the variable impact on perioperative outcomes for congenital heart patients is slowly becoming more apparent.
      See Article page e97.
      Bezerra and colleagues
      • Bezerra R.F.
      • Franchi S.M.
      • Khader H.
      • Castro R.M.
      • Liguori G.R.
      • da Silva L.F.
      • et al.
      COVID-19 as a confounding factor in a child submitted to staged surgical palliation of hypoplastic left heart syndrome: one of the first reports of SARS-CoV-2 infection in patients with congenital heart disease.
      report on an interesting case from São Paulo, Brazil, where, as of this writing in June 2020, coronavirus disease 2019 (COVID-19) is raging. This worldwide pandemic took clinicians by surprise and, as a consequence, there is a lot to catch up on, such as the different manifestations of this new disease, how it affects patients with congenital heart disease (CHD), and on how to prevent it. Writing from the one-time epicenter of the COVID-19 crisis in NYC, our team has unfortunately been confronted with patients with CHD infected with COVID-19 at different perioperative time periods, such as in asymptomatic patients coming from home for semielective surgery who tested positive on their polymerase chain reaction (PCR) nasal swab test, in a patient with cardiomyopathy on extracorporeal membrane oxygenation support who required a ventricular assist device while still positive, and in postoperative patients after Fontan and after truncus arteriosus repair (after testing negative on their preoperative PCR tests). The clinical manifestations were all extremely variable, very much in line with the present report, and affected many organ systems, including peripheral nerves, the gastrointestinal system, and others. Thus, our current experience is eerily similar to that of our Brazilian colleagues.
      All indications point to the fact that COVID-19 is going to be a significant disruption in our lives, personal and professional, for a minimum of 1 to 2 years. Thus, in the absence of a vaccine or targeted therapies, trying to elucidate the effect it has on our patients is important.
      Clearly, at a minimum, parents and other family members have to be screened for symptoms. Obviously, any child or any child with a family member with viral symptoms should be delayed. Ideally, every patient should be tested by PCR between 1 and 3 days before surgery (the State of New York currently accepts a negative test for up to 5 days before surgery). If positive, the surgery should be delayed for at least 2 weeks and until the patient tests negative. The role of antibody testing in the blood is unclear in this setting. Unfortunately, some countries may not have the capability of testing widely and early and thus may have to rely on the presence of viral symptoms and on the urgency of the surgery to triage patients.
      At least during the pandemic, and likely for a while after that, COVID-19 should be high on the list of differential diagnosis for any postoperative patient with CHD behaving abnormally or developing complications. This includes even patients without infectious (fever) symptoms. This is also important to protect health care workers (HCWs) caring for this patient.
      Some patients positive for COVID-19 will require open-heart surgery that cannot be delayed. Some evidence is emerging that the viral load and the presence of symptoms have a strong role to play in how manifest the inflammatory response will be. Thus, delay by even a few days might be beneficial. If that is not possible and the patient's life is at risk, then there is no choice but to proceed with surgery. All HCWs in the operating room should be wearing N-95 respirator masks if at all possible, for every case.
      In summary, we are just beginning to understand how COVID-19 will affect perioperative outcomes of patients with CHD. Currently, heightened vigilance with appropriate HCW protection and a liberal testing strategy, if available, are key.

      Reference

        • Bezerra R.F.
        • Franchi S.M.
        • Khader H.
        • Castro R.M.
        • Liguori G.R.
        • da Silva L.F.
        • et al.
        COVID-19 as a confounding factor in a child submitted to staged surgical palliation of hypoplastic left heart syndrome: one of the first reports of SARS-CoV-2 infection in patients with congenital heart disease.
        J Thorac Cardiovasc Surg. 2021; 161: e97-e101

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