Produção Nacional
Revisado por pares
Coronary Artery Bypass Surgery in Patients With COVID-19
2020; Lippincott Williams & Wilkins; Volume: 14; Issue: 1 Linguagem: Inglês
10.1161/circoutcomes.120.007455
ISSN1941-7705
AutoresPedro Sílvio Farsky, Diego Feriani, Barbara Valente, Maria A.G. Andrade, Vivian Lerner Amato, Larissa Carvalho, Aline Santos Ibanês, Luís Filipe de Souza Godoy, Renato Tambellini Arnoni, Cely Saad Abboud,
Tópico(s)Long-Term Effects of COVID-19
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 1Coronary Artery Bypass Surgery in Patients With COVID-19 Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBCoronary Artery Bypass Surgery in Patients With COVID-19What Have We Learned? Pedro Silvio Farsky, Diego Feriani, Barbara B.P. Valente, Maria A.G. Andrade, Vivian L. Amato, Larissa Carvalho, Aline S. Ibanes, Luiz F. Godoy, Renato T. Arnoni and Cely S. Abboud Pedro Silvio FarskyPedro Silvio Farsky Pedro Silvio Farsky, MD, Av Dante Pazzanese 500, Sao Paulo, SP, CEP 04012-180 Brazil. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7427-3237 Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). Hospital Israelita Albert Einstein, São Paulo, SP, Brazil (P.S.F., B.B.P.V., L.F.G.). , Diego FerianiDiego Feriani https://orcid.org/0000-0002-3733-6048 Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). , Barbara B.P. ValenteBarbara B.P. Valente Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). Hospital Israelita Albert Einstein, São Paulo, SP, Brazil (P.S.F., B.B.P.V., L.F.G.). , Maria A.G. AndradeMaria A.G. Andrade Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). , Vivian L. AmatoVivian L. Amato Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). , Larissa CarvalhoLarissa Carvalho Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). , Aline S. IbanesAline S. Ibanes Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). , Luiz F. GodoyLuiz F. Godoy https://orcid.org/0000-0002-6918-6865 Hospital Israelita Albert Einstein, São Paulo, SP, Brazil (P.S.F., B.B.P.V., L.F.G.). , Renato T. ArnoniRenato T. Arnoni Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). and Cely S. AbboudCely S. Abboud Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil (P.S.F., D.F., B.B.P.V., M.A.G.A., V.L.A., L.C., A.S.I., R.T.A., C.S.A.). Originally published11 Dec 2020https://doi.org/10.1161/CIRCOUTCOMES.120.007455Circulation: Cardiovascular Quality and Outcomes. 2021;14:e007455Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 11, 2020: Ahead of Print Coronavirus disease 2019 (COVID-19) caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to the pandemic, causing unprecedented health and social crisis worldwide.Patients with acute coronary syndromes, especially when coronary artery bypass graft (CABG) surgery is needed, may present with higher severity risk if affected by COVID-19. Extracorporeal circulation leads to activation of endothelium and microcirculatory network, which activates the coagulation, platelet aggregation, and inflammation.1 COVID-19 may also course with severe inflammation, massive secretion of inflammatory cytokines, plaque rupture, and a procoagulant state.2 Therefore, it is advisable to postpone surgeries interventions when possible. However, our institution is a public tertiary referral hospital for high-risk cardiovascular patients even in SARS-CoV-2 pandemic.We describe a series of 13 patients with high-risk coronary artery disease submitted to CABG and who had COVID-19 infection during the same hospitalization, 6 patients had COVID-19 before surgery, 3 patients were operated with active infection, and 4 patients were infected after surgery.All patients were admitted with severe multivessel coronary disease, with clinical features requiring emergency procedures. By the definition of cardiac surgery recommendations during COVID-19 by Patel et al,3 all patients were on high acuity cases and were not able to be discharged.Heart team decisions were made for all patients and infectious disease evaluation for COVID-19. We routinely tested for reverse-transcriptase polymerase chain reaction for SARS-CoV-2 24 to 48 hours before surgery. Positive or nonavailable COVID-19 tests had all personal protective equipment isolation measures in the operating room and isolated postoperative intensive care unit. During surgery, no extracorporeal circulation changes, were done in patients with COVID-19, and ultrafiltration was routinely used. Patients characteristics are summarized in Table.4,5Table. Patient characteristics.IDAge, ySexComorbiditiesSociety of Thoracic Surgeons score mortality scoreCardiological clinical featuresCT findings4Diagnostic interval COVID-19 until surgery, dCOVID-19 status at the operating roomCOVID-19 disease severity5Postoperative complicationPostoperative mechanical ventilation, dPostoperative ICU stay, dRenal replacement therapy during hospitalizationHospital length of stay, dClinical outcomesPreoperative 168FHYP/DM/HC1.23%Unstable anginaNA21RecoveredAsymptomaticAF16No35Discharge 269FHYP/DM/HC2.94%Non-STEMINA31RecoveredAsymptomaticAF/pulmonary septic shock55Yes35Death 369FHYP/HC/CKD/STK/TIA1.46%Unstable anginaNegative22RecoveredAsymptomaticAF/bleeding plus platelets transfusion34No46Discharge 460MHYP/HC/SM0.76%Unstable anginaNegative24RecoveredAsymptomaticSVT/severe encephalopathy2126No94Death 568FHYP/HC/SM2.00%Unstable anginaNA22RecoveredAsymptomaticNo17No35Discharge 673MHYP/DM/HC/PE2.47%Non-STEMITypical22RecoveredAsymptomaticNo17No38DischargeCOVID-19 intraoperative active disease 764MHYP/DM/HC/PE2.22%Non-STEMI/postinfarction anginaNA1Active diseaseIndeterminateIABP/refratary shock33Yes6Death 857FHYP/DM/HC4.47%Non-STEMI/postinfarction anginaNA1Active diseaseIndeterminateNo112Yes42Discharge 962FHYP/DM/HC1.22%Unstable anginaAtypical−1Active diseaseCriticalPulmonary septic shock68No23DischargeCOVID-19 postoperative 1050MHYP/DM/SM0.48%Non-STEMI/postinfarction anginaIndeterminate−5Pre symptomaticSeverePulmonary thromboembolism13No17Discharge 1163MNA0.70%STEMITypical−6Pre symptomaticSevereNo12No32Discharge 1243MHC/SM1.45%Non-STEMITypical−10Pre symptomaticCriticalBleeding plus platelets transfusion/preoperate acute myocardial infarction type 52829No56Discharge 1358FHYP/HC/COPD1.49%STEMINA−13Pre symptomaticModerateBleeding plus platelets transfusion/preoperate acute myocardial infarction type 517No34DischargeAF indicates Atrial fibrillation; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019; CT, computed tomography; DM, diabetes; HC, hypercholesterolemia; HYP, hypertension; IABP, intra aortic balloon pump; ICU, intensive care unit; NA, not available; PE, pulmonary embolism; SM, smoking; STEMI, ST-segment–elevation myocardial infarction; STK, stroke; SVT, supra ventricular tachycardia; and TIA, transient ischemic attack.Patients with positive reverse-transcriptase polymerase chain reaction for SARS-CoV-2 before surgery, waited at least 14 days or clinical symptoms resolution. After surgery, one died from septic shock and another patient died from severe encephalopathy. This encephalopathy had T2/fluid-attenuated inversion recovery hyperintense signal in hypothalamus and a diffuse microangiopathic pattern seen at brain magnetic resonance imaging. Two other patients had atrial fibrillation and 2 had no complications after surgery.Three patients were submitted to CABG at an emergent basis during active COVID-19 infection, because of clinical instability and before the PCR SARS-CoV-2 result was available. One died and the 2 others were discharged. This patient died in the third postoperative day of cardiogenic shock. The other patient, with a high surgical risk, did not develop important clinical manifestations of COVID-19 and was discharged 26 days after surgery. The third patient recovered from septic shock from lung origin. She presented with mild-lung signs of COVID-19 infection.Four patients had a negative reverse-transcriptase polymerase chain reaction in the 3 days before surgery and were infected in the postoperative period, in a medium time of 8.5 days after CABG. All 4 were discharged alive. They developed COVID-19 clinical manifestations that ranged from moderate to severe. One had a pulmonary embolism, and 2 had type 5 myocardial infarction.The authors declare that all supporting data are available within the article. This study was approved by an Institutional Review Committee.Emergent cardiac surgery did not stop in our hospital because of COVID-19 pandemic, and all stable cases were deferred. Since the begging of the pandemic, specific intensive care units and wards were opened for the suspected and confirmed cases. Visits were suspended as the companions. But even though, infections occurred.To the best of our knowledge, this is the first series of CABG patients with COVID-19 infection in the same hospitalization. Previous case description reported only single cases.6,7In our case series, we found a high rate of complications and in hospital mortality. Hypothalamic magnetic resonance imaging changes seen in the fourth patient had already been described in patients with COVID-19, an imaging feature that resembles Wernicke's encephalopathy.Although there are potential in common severe complications of both CABG and COVID-19, they are related to the severity of the SARS-CoV-2 infection and the risk of the cardiac procedure.A particularly important point is related to patients who were infected before surgery and waited sufficient time until resolution of symptoms. After the surgical procedure, they had a disproportionately high rate of death and complications.In our series, COVID infection after CABG did not result in severe complications.Protective measures to avoid COVID-19 infection are mandatory. We learned that patients with previous COVID-19 should wait as long as possible after clinical resolution, considering that unexpected CABG complications may occur.Sources of FundingNone.Disclosures None.FootnotesPedro Silvio Farsky, MD, Av Dante Pazzanese 500, Sao Paulo, SP, CEP 04012-180 Brazil. Email pedro.farsky@gmail.comReferences1. Kraft F, Schmidt C, Van Aken H, Zarbock A. Inflammatory response and extracorporeal circulation.Best Pract Res Clin Anaesthesiol. 2015; 29:113–123. doi: 10.1016/j.bpa.2015.03.001CrossrefMedlineGoogle Scholar2. 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Kuznetsov D, Gevorgyan A, Novokshenov V, Kryukov A, Polyaeva M, Lyas M, Khalmetova A and Duplyakov D (2021) Coronary artery bypass grafting in patients with coronary artery disease and COVID-19: search for an optimal strategy, Russian Journal of Cardiology, 10.15829/1560-4071-2021-4342, 26, (4342) January 2021Vol 14, Issue 1 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.007455PMID: 33302701 Originally publishedDecember 11, 2020 Keywordsacute coronary syndromeCOVID-19cytokinespandemicultrafiltrationPDF download Advertisement SubjectsCardiovascular SurgeryComplicationsMortality/Survival
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