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Review Article

Cardiothoracic Surgery Practice at a Tertiary Center during the

COVID‑19 Pandemic
Milind Hote, Sanjoy Sen Gupta
Department of CTVS, All India Institute of Medical Sciences, New Delhi, India

Abstract
A COVID‑19 pandemic has been declared by the WHO since January 2020. In this crisis, cardiac surgeons have to ensure that essential
cardiac surgery is available while ensuring that inadvertent COVID‑19 does not spread among patients or to the surgical team.

Keywords: COVID‑19, guidelines, modification, surgery

With the declaration of the COVID‑19 pandemic, medical hiding of COVID status/tested but coming false negative).
practice has changed and Cardiac Surgical practice has also In such a scenario, all the OT staff and ICU staff who
changed.[1‑5] Due to the lockdown and restricted travel, allocation come in contact with such a patient will be at jeopardy
of nursing staff and residents to COVID care and quarantine with the resulting health risk, quarantine difficulties, and
of any inadvertently exposed staff, there is shortage of staff in departmental “temporary loss” of a large number of staff
surgical units. Wards, beds, and ventilation equipped intensive at one go
care units (ICUs) are being kept reserved for potential escalation 2. The availability of personal protective equipment (PPE), in
of the COVID‑19 crisis. Blood banks cannot also provide full terms of quantity, is currently not adequate. The rationale
support as voluntary and patient‑related donors are limited is to preserve the meagre stock to be used only when really
due to fear of hospital visit‑related infections and also travel and absolutely necessary.
restrictions. In spite of this, cardiac surgical care has to continue 3. The problem of “isolating” a positive patient once operated
for critical cardiac problems without compromising patient and 4. The known high risk of mortality if patient is operated and
health personal safety.[6‑13] is COVID positive.
Elective surgery needs to be delayed because of the above The general guiding principle is thus SAFETY, of all
and because resources have been shifted to the care of
Since the lockdown was implemented, the outpatient
COVID‑19 patients. We need to decide on:
departments were shut down, and all routine admissions were
1. Types of patients which are to be deferred
stopped as per the directives from the administration and health
2. Patients which must be operated open
ministry.
3. The preparation of the surgical team and the ICU and the
operation theatre for the patient in the COVID‑19 setting.
Address for correspondence: Dr. Milind Hote,
The principals on which we are working currently are as follows: Professor, Department of Cardiothoracic and Vascular Surgery,
CT Centre, AIIMS, New Delhi ‑ 110 029, India.
The Department is presently operating only about 2%–4% of
E‑mail: [email protected]
its normal surgical case load.
The guiding principles are: Submitted: 23‑Mar‑2020 Revised: 25-Apr-2020
Accepted: 25-Apr-2020 Published: 06-May-2020
1. Possibility of COVID‑positive patient being inadvertently
operated in our operation theater (OT) (no detection/false
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DOI: How to cite this article: Hote M, Gupta SS. Cardiothoracic surgery practice
10.4103/jpcs.jpcs_35_20 at a tertiary center during the COVID-19 pandemic. J Pract Cardiovasc Sci
2020;6:105-7.

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Hote and Gupta: Cardiac surgery in the COVID‑19 pandemic

Subsequent to that, the working wisdom has been to do only • Operating team should be small and don full PPE. It has to
the real genuine emergency cases which are of the following be kept in mind that sternotomy and airway manipulation
nature – will generate aerosol
1. Type A aortic dissection • There have to be designated PPE donning and doffing areas
2. Coronary artery disease (CAD) spectrum ‑ Severe unstable for all personnel; the staff disposing of the discarded PPE
angina/severe left main disease angioplasty complications, should be fully conversant with the correct procedure and
acute coronary syndrome with mechanical complications perform its task without errors
3. Stuck prosthetic valves, not thrombolysis responsive, • Postoperative convalescence ‑ After the emergency
class 1V surgery, all patients are shifted only to a different fully
4. Obstructed total anomalous pulmonary venous return, dedicated ICU [Figure 2] where senior residents and
refractory spells, cardiac tamponade patients nursing staff on duty are to be provided with PPE and
5. Some other congenital heart problems, which if delayed, rotated in three shifts per day along with a separate
may deteriorate beyond a point to cause lifelong donning and doffing area. A patient is shifted out of
morbidity (Transposition of great arteries (TGA) with that ICU only after the day 5 COVID sample report is
regressing ventricle). available. Patients with negative report will safely join
those in regular ICU where already left over patients
before lockdown are still recuperating.
Protocol for Preoperative Management
Nursing in‑charge of the ward ensures the availability of 10
• These patients undergo mandatory clinical screening
PPE kits at all times.
by the department of infectious diseases (IDs) before
• Any patient who has been operated in CTVS department
admission, whereby the patients with or without symptoms
previously and now has any symptom suggestive
will be considered as COVID‑19‑positive unless proven
of postoperative complication, can have telephonic
otherwise by swab test consultation with our post MCh senior residents and get
• Two cubicles in step down ward [Figure 1] have been appropriate advice. If his/her coming to hospital is deemed
allocated to admit all new patients. A single nursing staff necessary, they are advised to come ONLY to AIIMS
with proper PPE is allocated in each cubicle. Senior Emergency and not directly to CTVS wards. In emergency
resident on duty has to wear appropriate PPE (N95 mask, ward, they are appropriately evaluated, triaged as per their
face shield and gloves) before interacting with the isolated COVID status and admitted in the appropriate area
patients. Covid‑19 swabs will be taken on Day 0 and Day • All healthcare personnel are instructed to be very vigilant
5 by the Emergency ID team. Blood sampling is done about any symptoms as are seen with COVID infection
with adequate precautions. The blood bank is informed and if they are symptomatic, the clinical algorithm to be
beforehand about sending of these samples. If positive, followed fully by them (Reporting to emergency COVID
surgery not be done on these patients. If COVID‑negative/ screening area, getting appropriate advice and triage as per
cleared for surgery by ID team, they may be taken up for symptom severity and report positivity).
surgery
Till now, we are yet to operate on a preoperatively confirmed
• Precautions outlined during perioperative period ‑
COVID‑positive patient. In the patients that have been
Anesthesia induction to be done with minimum staff, with
operated (about 12 since March 25, 2020), the COVID tests
full PPE gear
done postoperatively have been negative.
We anticipate that if the COVID case load increases suddenly
and some proportion of these patients fall very sick, so as to be

Figure 1: Step down ward. Figure 2: Intensive care unit for CTVS patients.

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Hote and Gupta: Cardiac surgery in the COVID‑19 pandemic

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