A survey of minimally invasive cardiac surgery during the COVID-19 pandemic

Abstract

Background: Lack of scientific data on the feasibility and safety of minimally invasive cardiac surgery (MICS) during the COVID-19 pandemic has made clinical decision making challenging. This survey aimed to appraise MICS activity in UK cardiac units and establish a consensus amongst front-line MICS surgeons regarding standard best MICS practise during the pandemic. Methods: An online questionnaire was designed through the ‘googleforms’ platform. Responses were received from 24 out of 28 surgeons approached (85.7%), across 17 cardiac units. Results: There was a strong consensus against a higher risk of conversion from minimally invasive to full sternotomy (92%; n = 22) nor there is increased infection (79%; n = 19) or bleeding (96%; n = 23) with MICS compared to full sternotomy during the pandemic. The majority of respondents (67%; n = 16) felt that it was safe to perform MICS during COVID-19, and that it should not be halted (71%; n = 17). London cardiac units experienced a decrease in MICS (60%; n = 6), whereas non-London units saw no reduction. All London MICS surgeons wore an FP3 mask compared to 62% ( n = 8) of non-London MICS surgeons, 23% ( n = 3) of which only wore a surgical mask. London MICS surgeons felt that routine double gloving should be done (60%; n = 6) whereas non-London MICS surgeons held a strong consensus that it should not (92%; n = 12). Conclusion: Whilst more robust evidence on the effect of COVID-19 on MICS is awaited, this survey provides interesting insights for clinical decision-making regarding MICS and aids to facilitate the development of standardised MICS guidelines for an effective response during future pandemics.

The ongoing impact of COVID-19 on adult cardiac surgery and suggestions for safe continuation throughout the pandemic: a review of expert opinions

“…15 Again, risk: benefit stratification is implemented; the limitations and detriment caused to surgeons, and thus patients, by potentially unnecessary PPE, versus the extent of protection provided to an already limited, invaluable workforce. 18,20 Additional measures for infection control have particularly implicated the process of anaesthestics, wherein extubation and its associated coughing creates necessity for additional precautionary measures in reducing staff exposure to COVID-19. As a minimum, disposable equipment is strongly encouraged and extubation and recovery should take place inside the theatre, a designated 'dirty zone' , ensuring the scrub room and anaesthetic room remain uncontaminated.…”

“…14 Concern also arises, that, in the reducing the number of cardiac surgeries, and the need to work within the ICU, that cardiac surgeons may deskill, illustrating that the long term effects for clinicians could be as uncertain as those for patients. 18,20,23 Length of hospital stay and follow-up. Appropriate and efficient planning is required to ensure that LOS is minimised, in all aspects, but especially in critical care.…”

“… 18 , 30 Despite a positive association with reduced post-operative infection, faster recovery and thus reduced LOS, due to its relatively novel nature, there has been a decrease in minimally invasive cardiac surgery (MICS), such as minimally invasive mitral valve repair and minimally invasive mitral valve replacement during the pandemic. 18 , 20 Experts agree that emergency procedures should only take place via conventional methods of full sternotomy. 18 However, overwhelming expert consensus suggests there is no greater risk of adverse outcomes when compared to conventional methods in the peri-pandemic period and regardless of COVID-19 status.…”

“… 10 , 13 – 18 CT may still be used in emergency cases to maintain COVID-free hospitals and prevent the life-threatening implications of an outbreak in such areas. 18 – 20 Likely, a combination of NAAT, CT and antibody detection would be optimal for reducing false negative rates, however is impractical and costly. Debate still remains as to whether all cases should be assumed positive despite a negative swab, requiring all patients to quarantine for 2 weeks prior to admission.…”

“…Debate still remains as to whether all cases should be assumed positive despite a negative swab, requiring all patients to quarantine for 2 weeks prior to admission. 13 – 20 Since the presence of coronavirus symptoms, or positive test, heavily influences the decision to undergo surgery, adequate screening tools are a vital pre-operative addition. They not only ensure minimum risk of transmission to other patients and crucial specialist staff; surgeons, perfusionists and critical care workers, but also a reduction in length of hospital stay and enabling beds to be vacated.…”