The coronavirus disease 2019 (COVID-19) pandemic has impacted congenital cardiac surgical
programs with significant reduction in case load, implementation of patient triage
strategies, and development of personal protective equipment (PPE) guidelines. This
document summarizes current status and implications of COVID-19 in congenital cardiac
surgery outlining recommendations from the Congenital Cardiac Anesthesia Society (CCAS;Figure
1).
Figure 1.
Considerations for Pediatric Heart Programs during COVID-19 pandemic, postpandemic,
and the future. COVID-19 indicates coronavirus disease 2019; PPE, personal protective
equipment.
REORGANIZATION OF HEART PROGRAM
Decrease in CaseLoadand Prioritization
In response to the rapid recognition of challenges faced by health care infrastructures
related to the COVID-19 outbreak, a broad call to restrain “elective” surgical procedures
was announced by the Center for Medicare and Medicaid Services (CMS) and the American
College of Surgeons (ACS) in March 2020.
1
Multidisciplinary committees should discuss cases prioritization based on ACS definition
of emergent and urgent procedures, taking into consideration hospital capacity and
local resources available during the COVID-19 pandemic (Table).
2
Table.
Cardiac Lesions and Surgical Prioritization
Elective Cases
Urgent Cases
Emergency Cases
No anticipated risk as a result of delaying the procedure more than 2 mo
Risk of patient deterioration or rapid disease progression if the procedure is delayed
days to weeks
Delay more than 24–48 h is life threatening
Medically managed arrhythmias that is not lifethreatening awaiting an electrophysiologic
study/ablation.Valvular regurgitation that is managed medically.Slowly progressive
aortic stenosis scheduled for Ross operation.Pre-Fontan catheterization with adequate
saturations (>75%) on room air.
Transposition of the great arteries with intact ventricular septum (delay <1wk) and
with ventricular septal defect (2–4wk).Hypoplastic left heart syndrome with restrictive
atrial septum (Norwood procedure).Truncus arteriosus.Obstructive lesions that are
stabilized with prostaglandins.Superior cavopulmonary anastomosis with decreasing
saturations.Atrioventricular canal in a patient on “maximal” anticongestive therapy
with failure to thrive and repeat hospitalization.Endocarditis with a hemodynamically
stable patient.
Obstructed total anomalous pulmonary venous return.Heart transplant.ECMO or VAD placement
in hemodynamically unstable patient.PDA stents in an unstable patient on prostaglandin.AAOCA
with recent hemodynamic instability.Stenotic RV-PA conduitwith severe ventricular
dysfunction.Thrombosed shunt.Tamponade.Balloon atrial septostomy.
Abbreviations: AAOCA, anomalous aortic origin of a coronary artery; ECMO, extracorporeal
membrane oxygenation; PDA, patent ductus arteriosus; RV-PA, right ventricle to pulmonary
artery; VAD, ventricular assist device.
Heart Transplantation
To date, most pediatric heart transplant programs in the United States continue to
deem heart transplant as an urgent/emergent surgical procedure. The recommendation
from the International Society of Heart and Lung Transplantation states that the patient
should report no new-onset clinical symptoms consistent with COVID-19, no close contact
with a confirmed case, and no travel within 14 days (https://ishlt.org/ishlt/media/documents/SARS-CoV-2_-Guidance-for-Cardiothoracic-Transplant-and-VAD-centers.pdf).
In addition, the document recommends COVID-19 testing before transplant, assuming
a rapid turn-around assay is available. Patients with positive severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) infection should not undergo transplantation.
In regard to the processes that surround donor offers and procurement, the surgical
recovery of organs by the local teams should be promoted whenever possible to minimize
potential exposure and traveling across the country.
Monitoring the WaitList
Most congenital cardiac programs ceased scheduling elective procedures in anticipation
of the surge in COVID-19–positive patients requiring hospitalization. This has resulted
in a dynamic expanding procedural wait list which will have to be managed with consideration
of the following:
Continuously reassessing and reprioritizing of all patients on list
a.
Implementing telehealth, virtual check-in, and/or remote monitoring
Recognition that every patient’s clinical status and pending procedure is unique and
a decision to further postpone must be multidisciplinary based on:
a.
Potential for significant deterioration which could result in harm such as therapy
otherwise not indicated, prolonged hospital stay, or mortality
b.
Institutional abilities to schedule cases (physical plant, human resources)
c.
Time course of COVID-19 crisis
Ongoing effective, timely communication with patients/families, referring physicians,
and proceduralists
As restrictions lessen, a plan needs to be in place not only for caring for the remaining
patients on the wait list but also for addition of new patients.
Resumption Of Activity
In the COVID-19 outbreak, defining the transition of pandemic to postpandemic remains
unclear. The stringency and duration of strategies such as physical distancing and
PPE use will impact the timing and magnitude of a potential “second wave” of infections
which may prolong the pandemic phase. Formal documentation of herd immunity by testing
individuals’ immune status may help define a stable SARS-CoV-2 resilient health care
workforce, allowing faster return to higher surgical volumes. Prioritization based
on medical needs across surgical specialties is important as many pediatric cardiac
centers will share resources (eg, personnel) with other surgical specialties. Monitoring
for clinical deterioration during recommended wait times mitigates harm, affords opportunities
to inform future care plans, and provides a structured and just approach to return
of surgical services.
Resuming Activityin Practice
In the recovery phase following the COVID-19 pandemic, delayed surgeries will need
to be rescheduled. This will likely require overtime shifts and expanded utilization
of currently available operating rooms and catheterization laboratories. In some institutions,
additional operating rooms may be allocated to meet this demand, but that approach
assumes that perioperative personnel can be mobilized. In many institutions, cardiac
intensive care unit (CICU) and step-down cardiac floor capacities are a limiting factor
in the number of cases that can be performed. Programs that have well-established
“fast-track” protocols will be able to leverage that expertise to help relieve potential
congestion in the CICU and step-down floor. In each program, serious consideration
will have to be given to further delaying procedures associated with long CICU and
hospital stays in favor of performing procedures with short stays. To put a finer
point on it, a program may not be able to justify performing a procedure with an average
CICU stay of 6–7 days in place of performing multiple cases with an average CICU stay
of 1–2 days. “Fast-track” surgical procedures and diagnostic catheterizations could
be performed on the weekend to reduce the inpatient volume during the week. Alternatively,
these patients could be recovered in an extended recovery room environment allowing
the CICU and step-down units to handle a larger caseload.
DIAGNOSTIC TESTING FOR SARS-COV-2
The purpose of testing is to facilitate diagnosis to guide supportive patient management
and to implement measures to limit the spread of the virus. There are 2 broad categories
of SARS-CoV-2 tests: those that detect the virus itself and those that test for the
immune response of the host to the virus.
Tests for ViralRNA
The preferred testing method is the real-time reverse transcription-polymerase chain
reaction (RT-PCR). Within 5 days of the onset of symptoms of COVID-19, patients have
high viral loads in their upper and lower respiratory tracts.
3
A nasopharyngeal or oropharyngeal swab may be used to collect a specimen. For patients
with pneumonia, lower respiratory tract secretions may be collected from bronchoalveolar
lavage fluid. Detection rates in each sample vary between patients and may change
over the course of their illness.
4
Testing patients for SARS-CoV-2 helps identify those who are infected, which is useful
for individual patient management, as well as for implementing mitigation strategies
to prevent spread in health care facilities and the community. It may also help with
the appropriate choice of PPE for health care providers. Although these tests have
become more widely available, the huge demand for them has created supply chain challenges.
One of the current limitations regarding preoperative testing for SARS-CoV-2 comes
from the variability in sensitivity and specificity of the different tests available.
5
The rate of false negative for some of those tests can be as high as 30%. It is therefore
extremely important to consider the sensitivity and positive predictive value of the
test used in each institution before a decision to deescalade the level of PPE can
be made. The vast majority of heart programs have started testing inpatients and outpatients
scheduled for cardiac surgery and cardiac catheterization.
Antibody Tests
Antibody tests can identify individuals who have been exposed to SARS-CoV-2 and have
developed immunity, which could protect them from future infections. Development of
immunity may enable previously infected health care workers to return to work with
relative safety.
6
Congenital heart programs could consider deployment of these individuals to environments
where the risk of infection is highest thereby protecting nonimmune members of the
workforce from infection.
MINIMIZING THE IMPACT OF EXPOSURE TO COVID-POSITIVE INDIVIDUALS ON SMALL DEDICATED
TEAMS
Cardiac anesthesia teams are composed of a small number of dedicated attendings and
extended care providers. If a substantial number of cardiac anesthesia team members
become ill or need to self-isolate due to exposure to a COVID-19–positive patient,
colleague or family member, normal care delivery cannot be sustained. Segregating
anesthesia providers and other cardiac specialty members into teams that are kept
isolated from each other minimizes the risk of virus transmission. Attempting to operationalize
team separation is challenging when faced with 24/7/365 coverage, simultaneous emergencies
and illness (COVID-19 or otherwise), or exposure of one or more team members to a
positive patient.
AIRWAY MANIPULATION
Aerosol-generating medical procedures (AGMP), such as endotracheal intubation and
extubation, mask ventilation, tracheal suctioning, and inadvertent lung injury during
positive pressure ventilation produce significant amounts of aerosolization and may
be a significant source for the spread of SARS-CoV-2.
7
Careful airway management of suspected or infected patients is therefore crucial.
Adequate muscle relaxation and rapid sequence induction are recommended to avoid mask
ventilation.
8
Cuffed tubes should be utilized to minimize gas leaks. Selection of the nasal or oral
route for intubation should be based on institutional experience and preference with
consideration given to the priority of rapidly securing the airway. Once the trachea
is intubated and the endotracheal tube secured, an inline suction device should be
placed to avoid inadvertent contamination of the environment during tracheal suctioning.
A high-efficiency particulate air (HEPA) filter should routinely be placed distal
to the Y-connector of the circle system in addition to the filters normally placed
on the inspiratory and expiratory limbs. Regardless of the site of extubation, appropriate
PPE and room decontamination is essential.
PPE IN THE OPERATIVE ROOM OR THE CARDIAC CATHETERIZATION SUITE
In COVID-19–positive patients or suspected patients, PPE must be worn at all times.
In asymptomatic patients who have not undergone COVID-19 testing, PPE is recommended
during AGMP. Some institutions with well-established COVID-19 testing are relaxing
the requirement for PPE during AGMP for patients who have tested negative in the preceding
24 hours. PPE should, at a minimum, include properly fitted N95 masks, eye and face
shields, fluid impervious gowns, and gloves. When available, additional equipment
such as positiveairwaypurifyingrespiratorsshould be considered to further reduce the
risk of exposure. In all patients, except those tested to be negative for COVID-19,
all nonessential personnel should be a minimum of 6 feet from the patient or ideally
outside the room during AGMP. Only the minimum number of properly trained personnel
should be in attendance during any AGMP. The use of video laryngoscopes is highly
recommended both to assist in airway visualization and to maximize the distance from
the patient to the caregiver’s face during the procedure. It is recommended that a
“COVID” cart with all of the appropriate equipment be placed immediately outside the
patient’s room to minimize time acquiring the necessary items. Finally, it is the
responsibility of the provider to properly dispose of all contaminated materials into
a double-sealed bag at the conclusion of the procedure while gowned in PPE to avoid
accidental contamination of environmental staff.
To prevent contamination of anesthesia and perioperative personnel and workspace equipment,
perioperative simulation should be promoted. Checklists should be created in collaboration
with Surgical Quality and Safety teams.
CARING OF NEWBORN WITH CONGENITAL HEART DISEASE BORN OF A COVID-19–POSITIVE MOTHER
In retrospective analyses of neonates born to mothers with suspected or confirmed
COVID-19, many newborns remained COVID-19 negative, but several exhibited respiratory
distress and death havebeen reported.
9,10
In 1 cohort, 3 newborns who were infected with SARS-CoV-2 had positive nasal and anal
swabs at days 2 and 4 of life. All 3 experienced fever, lethargy, and pneumonia and
were nasal swab negative by day 6 or 7 of life.
10
The most likely route of transmission of SARS-CoV-2 frommother to newborn is via respiratory
droplets during close contact. In the setting of acute maternal COVID-19 shortly before
birth, maternal antibody production and fetal passive immunity may not have had time
to develop, leaving the neonate relatively defenseless.
11
There is currently no evidence of vertical transmission of SARS-CoV-2 from mother
to fetus.
Multidisciplinary planning must occur ideally before and certainly after the birth
of a child with CHD who is born of a suspected or confirmed COVID-19 mother. Severe
COVID-19 symptoms in the mother may lead to fetal distress and preterm labor and delivery,
which may gravely impact the newborn cardiopulmonary physiology.
9
After delivery, the cord should be immediately clamped and the neonate isolated from
the mother. If transport is required to the pediatric hospital after birth, full PPE
is required throughout all phases. The newborn should be isolated and closely monitored
for symptoms for 14 days. If emergent surgery is required, the operating room team
must treat the newborn as SARS-CoV-2 infected and observe strict isolation procedures.
In the middle ground are the neonates with lesions typically treated nonemergently
within the first few days of life, such as the Norwood or arterial switch operations.
The risks and benefits of proceeding with surgery versus waiting must be carefully
weighed by a multidisciplinary team on a case by case basis.
CARDIOVASCULAR IMAGING
Echocardiography represents the primary imaging modality for diagnosis, management,
and long-term surveillance of these patients. In response to the spread of COVID-19,
the American Society of Echocardiography (ASE) has recently published a statement
addressing protection of patients and echocardiography service providers to prevent
viral transmission. Based on the recognition that children and those affected by CHD
represent potential confounding elements in this pandemic, recommendations specific
to the pediatric, fetal, and CHD populations have also been outlined in a supplement
statement.
12
These are based on acknowledging known differences between the pediatric and adult
populations in terms of COVID-19 prevalence, symptomatology, and disease severity
and other factors that impact imaging.
13
Most echocardiography laboratories have adopted these ASE recommendations which CCAS
supports. Key points of these continually updated guidelines suggest that echocardiographic
studies be performed when they are expected to provide clinical patient benefit based
on established appropriate use criteria with other examinations to be deferred/rescheduled.
14
It is desirable to determine patient COVID-19 status whenever possible, to limit provider
exposure during the examination, and to prevent equipment/reading room transmission.
Performance of transesophageal echocardiography (TEE) imaging is considered to increase
the risk of SARS-CoV-2 spread secondary to both droplet and aerosol transmission.
Currently, nonessential TEE examinations and those unlikely to impact clinical care
have been or are being postponed or canceled. In many adults with CHD, these studies
take place in sedated, nonintubated patients,a circumstance that could provoke aerosolization
of a significant number of viral particles in infected patients. Consequently, alternative
imaging modalities should be considered outside clinical settings that strongly merit
the use of TEE such as during urgent or emergent cardiac surgery in neonates, children,
and adults with CHD, and selected nonelective catheter-based interventions. Other
situations require careful assessment of the benefit of the TEE study versus risks
related to potential COVID-19 exposure and should also consider available PPE resources.
Although epicardial echocardiography is considered a valuable adjunct to intraoperative
imaging, TEE is known to overcome many of its limitations. Accordingly, during the
COVID-19 pandemic, standardized TEE algorithms should be developed in conjunction
with all stakeholders and influenced by local institutional policies, that consider
study indications and COVID-19 status to guide procedural precautions and the use
of PPE, as well as protocols for equipment handling, allowing for ongoing patient
benefits and the safest application of the imaging modality.
12,15
CARDIOPULMONARY BYPASS AND ANTICOAGULATION FOR COVID-19 PATIENTS
There are currently no reported cases of children with known COVID-19 undergoing cardiac
surgery with cardiopulmonary bypass (CPB). There is no evidence that the anticoagulation
strategy for a patient undergoing a procedure on CPB should be altered due to COVID-19,
but the cardiac care team should be aware that the thrombosis risk is increased in
this population.
16
In the event CPB is utilized in a patient with COVID-19, scavenging of exhaust gas
from the CPB machine is recommended. Currently, there are publications from China
showing the COVID-19 virus in the blood.
17
This would indicate it may be possible to transmit the virus to the exhaust ports
of an oxygenator and out into the environment. However, plasma leakage into the hollow
fiber oxygenator is the most likely way for the virus to be aerosolized from the CPB
circuit. Fortunately, when oxygenators are used as recommended, plasma leakage is
extremely uncommon. Scavenging systems are easy to apply and already utilized in many
centers that routinely deliver inhaled anesthetic gases during CPB.
BLOOD SHORTAGE AND CONSERVATION
Although the reduction in elective cases has decreased blood product utilization,
social isolation measures have resulted in a rapid decrease in overall blood donations.
Daily communication with the blood center and key clinical teams is necessary to predict
whether inventory is available to cover daily needs.
As cardiac anesthesiologists, it is our duty to implement perioperative blood conservation
strategies. Blood conservation guidelines for neonates and children undergoing cardiac
surgery have been published and provide a resource to help develop institutional protocols.
18
Although not well studied in children with CHD, preoperative treatment of anemia and
iron deficiency should be considered with either oral or intravenous iron. An erythropoietin
stimulating agent may be considered in specific cases. Prophylactic administration
of an antifibrinolytic should be used when appropriate. Efforts should also be made
to minimize the resultant hemodilution of CPB, including reduction of the prime volume
and the use of a nonblood prime in infants weighing >5 to 7 kg.
19
Because units of red blood cells are aging, blood banks may not be able to provide
fresh blood for neonatal cardiac patients. Due to the risk of hyperkalemia associated
with older and large volume transfusions, physicians should be vigilant regarding
the age of blood products received, the need for irradiation, and the use of washing
techniques before transfusion. Nonallogeneic coagulation agents, like desmopressin,
fibrinogen concentrate,
20
or prothrombin thrombin complex concentrate, may be considered based on underlying
coagulopathy. Multimodal center-specific transfusion algorithms (Figure 2) using a
restrictive approach and coagulation assessment based on either standard coagulation
tests or viscoelastic tests have been shown to be effective in reducing transfusion
requirements.
Figure 2.
Toolbox for blood conservation that can be used as an example to design institutional
toolbox. CT indicates clotting time; EACA, epsilon amino caproic acid; EXTEM, extrinsic
test from thromboelastometry; FC, fibrinogen concentrate; FEIBA, factor eight inhibitor
bypassing activity; FFP, fresh frozen plasma; FIBTEM, fibrinogen test from thromboelastometry;
IDA, iron-deficiency anemia; MUF, modified ultrafiltration; PCC, prothrombin complex
concentrate; PLT, platelets; RBC, red blood cell; TXA, tranexamic acid.
SUMMARY
The COVID-19 pandemic has impacted congenital cardiac surgical programs with significant
reduction in case load, implementation of patient triage strategies, and development
of PPE guidelines. Our opinion piece is based on current knowledge and experience.
Due to the lack of robust evidence, strategies will be evolving, and recommendations
will certainly change over the next months. It is important that congenital cardiac
surgical programs collect data to understand the impact of the COVID-19 pandemic on
the incidence of adverse events and resource utilization.
DISCLOSURES
Name: David Faraoni, MD, PhD.
Contribution: This author invited the coauthors, created the outline, wrote the manuscript,
edited and formatted the draft.
Name: Lisa A. Caplan, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: James A. DiNardo, MD, FAAP.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Nina A. Guzzetta, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Wanda C. Miller-Hance, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Gregory Latham, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Mona Momeni, MD, PhD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Susan C. Nicolson, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: James P. Spaeth, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Katherine Taylor, BMed MMed, FANZCA.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Mark Twite, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: David F. Vener, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Luis Zabala, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
Name: Viviane G. Nasr, MD.
Contribution: This author helped write the manuscript, reviewed and approved the final
version.
This manuscript was handled by: Jean-Francois Pittet, MD.