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“The compass of accurate knowledge directs the shortest, safest, cheapest course to any destination.”
– Claude C. Hopkins
Abstract
The novel coronavirus disease 2019 (COVID-19) pandemic has swept across the United States, leaving a wake of unprecedented disruption. At the front lines, hospitals have swiftly enacted large-scale structural and organizational changes in order to meet the unique challenges of the pandemic. Based on the recommendations of the Centers for Medicare and Medicaid Services (CMS),1 most hospitals across the United States have significantly curtailed all non-emergent procedures in an effort to conserve resources for a potential surge in severe COVID-19 infections. Consequently, cardiac surgeons have found themselves in uncharted waters due to indefinite cancellation of elective cardiac surgery. At the same time, while some patients with surgical-level cardiovascular disease have been left unable to access definitive treatment, others are avoiding the hospital altogether for fear of infection.2-4 What has become clear amidst the flux and uncertainty of the pandemic is that we must find a way to remain available to our patients by charting a safe and expeditious path toward resumption of elective cardiac surgery.
At the urging of the federal government,5 hospitals across the nation have slowly begun to plan for phased reopening of elective surgery. Although guidance statements such as those from the American College of Surgeons exist,6 the unique position of cardiac surgery within the spectrum of all elective surgery warrants specialty-specific considerations. Our patients are particularly tenuous and face an elevated risk of morbidity and mortality while waiting for surgery. Escalation of a case from elective to urgent based on clinical deterioration is not uncommon in our field. Elective cardiac surgery also requires substantially more resources (e.g., mechanical ventilation, blood products, inotropic medications, intensive care beds) compared to many of the other surgical subspecialties. Finally, the deleterious effects of cardiopulmonary bypass on the lungs may render these patients especially vulnerable to severe COVID-19 infection; however, evidence on this subject is purely speculative. Taken together, these unique challenges underscore the need for a specialty-specific roadmap. In the context of limited evidence at this time, we provide initial considerations for programs embarking on paths toward phased reopening of elective cardiac surgery.