Adult cardiac surgery in Trinidad and Tobago during the COVID‐19 pandemic: Lessons from a developing country

Abstract Background and Aim The coronavirus disease 2019 (COVID‐19) pandemic has seen the cancellation of elective cardiac surgeries worldwide. Here we report the experience of a cardiac surgery unit in a developing country in response to the COVID‐19 crisis. Methods From 6th April to 12th June 2020, 58 patients underwent urgent or emergency cardiac surgery. Data was reviewed from a prospectively entered unit‐maintained cardiac surgery database. To ensure safe delivery of care to patients, a series of strict measures were implemented which included: a parallel healthcare system maintaining a COVID‐19 cold site, social isolation of patients for one to 2 weeks before surgery, polymerase chain reaction testing for COVID‐19, 72 hours before surgery, discrete staff assigned only to cardiac surgical cases socially isolated for 2 weeks as necessary. Results The mean age at surgery was 59.7 ± 11 years and 41 (70.7%) were male. Fifty‐two patients were hypertensive (90%), and 32 were diabetic (55.2%). There were three emergency type A aortic dissections. Forty‐seven patients underwent coronary artery bypass graft surgery with all but three performed off‐pump. Fourteen cases required blood product transfusion. One patient had postoperative pneumonia associated with chronic obstructive pulmonary disease. The median length of stay was 5.7 ± 1.8 days. All patients were discharged home after rehabilitation. There were no cases of COVID‐19 infection among healthcare workers during the study period. Conclusion These strategies allowed us to maintain a service for urgent and emergency procedures and may prove useful for larger countries when there is decrease in COVID‐19 cases and planning for the restart of elective cardiac surgery.


| INTRODUCTION
The coronavirus disease (COVID-19), since December 2019, has had vast and far reaching effects in over 190 countries around the world. 1 As of 17th June 2020, the World Health Organization (WHO) reports approximately eight million confirmed cases with 440,000 deaths worldwide. 2 4 This has resulted in unique conditions for the continuation of urgent and emergency surgery despite the cancellation of an estimated 28 million elective surgeries worldwide at the peak of the pandemic. 5 We sought to explore the Trinidadian perspective during this pandemic and assess its impact on a cardiac surgery service after the implementation of the country's COVID-19 regulations. It is essential to reflect on the effects of the pandemic foremostly to validate and inform practice in the likely event of a second wave, but also to contribute to the global understanding of response to this disease. As such, the goals of this communication are to report on the conditions that allowed continuation of emergency and urgent elective cardiac surgical cases during the COVID-19 pandemic. We reviewed prospectively entered data from the unit maintained cardiac surgery database of consecutive patients.

| MATERIALS AND METHODS
During the reported COVID-19 period we did not operate on elective cases. A patient was defined as elective if they do not require urgent surgery and has been placed on a waiting list (before COVID-19 the waiting list was around 2-3 months). The number of procedures performed before COVID-19 was approximately 35 cases per month.
All patients were reviewed in our preoperative clinic with enforced social distancing in waiting rooms and mandatory mask wearing. Cases were screened by a multidisciplinary cardiac surgical team. Patients were selected on the basis of requiring urgent intervention (unstable angina, symptomatic aortic stenosis, poor ejection fraction) or emergency (acute type A aortic dissection).
Urgent patients identified according to the above criteria by the multidisciplinary cardiac surgical team were asked to socially isolate themselves at home before scheduled surgery for at least 7 to 14 days. All patients were intubated with minimum staff in the operating theater including an anaesthetist and an assistant with appropriate PPE (N-95/visor) to protect the team and diminish the chance of in-hospital "community spread." The surgical team wore standard surgical masks, gowns, and protective loupes. All cardiac surgical patients were managed in an intensive care unit (ICU) and high dependency unit (HDU) (not exposed to noncardiac surgery patients) by staff dedicated to their care only.

| RESULTS
The demographic and clinical data are summarized in Table 1   In the period examined, 58 cases deemed urgent or emergency were performed, with no hospital mortality. To optimize outcomes and protect both patients and staff in these instances, consideration of patients' COVID-19 status was viewed as paramount. All cardiac surgery patients at the private center, were required to self-isolate for one to 2 weeks and underwent PCR testing 72 hours before surgery. Isolation was also implemented for patients in the public hospital. However, we were unable to routinely screen patients for  blood products were able to be overcome with the use of cell saver machines. Additionally, though a smaller population of cardiac surgery patients, clinics continued to be carried out face-to-face with social distancing and use of masks, and therefore did not see the uptake of telemedicine seen in larger countries.
We recognize that these strategies proven viable in Trinidad cannot necessarily be generalized regardless of population size or infections rates, as many other confounding factors exist between countries and healthcare systems. Despite this however, several lessons may be derived from our unique situation, which may prove useful in guiding our neighbors' own unique circumstances.
To ensure safe delivery of care to patients, a series of strict measures were implemented which included: a parallel healthcare system maintaining a COVID-19 cold site, social isolation of patients for one or 2 weeks before surgery, whenever possible PCR testing for COVID-19, 72 hours before surgery, discrete staff assigned only to cardiac surgical cases socially isolated for 2 weeks as necessary. Screening of patients should be an essential component of any major elective cardiac surgical service that plans to continue throughout the pandemic or in the event of a second wave. These strategies allowed us to maintain a service for urgent and emergency procedures and may prove useful for larger countries when there is decrease in COVID cases and planning for the restart of elective cardiac surgery.

| CONCLUSION
Urgent and emergency cardiac surgery can be safely performed during the COVID-19 pandemic provided that certain precautions are taken. This experience confidently yet cautiously prepares us if there is a second wave of COVID-19 infections worldwide.