Cardiac Surgery Division.
Italian Society for Cardiac Surgery Task Force on COVID-19 Pandemic, Milan, Italy.
Ann Surg. 2020 Oct;272(4):e275-e279. doi: 10.1097/SLA.0000000000004393.
The aim of this study was to describe the clinical course of a consecutive series of patients operated of urgent cardiac surgery during COVID-19 outbreak.
In Italy, COVID outbreak has mostly occurred in the metropolitan area of Milan, and in the surrounding region of Lombardy, and previously "conventional" hospitals were converted into COVID spokes to increase ICU beds availability, and to allow only urgent CS procedures.
Among urgent CS patients (left main stenosis with unstable angina, acute endocarditis, valvular regurgitation with impending heart failure), 10 patients (mean age = 57 ± 9 years), despite a negative admission triage, developed COVID-pneumonia postoperatively, at a median of 7 days after CS.
Patients showed typical lymphopenia, higher prothrombotic profile, and higher markers of inflammation (ferritin and interleukin-6 values). At the zenith of pulmonary distress, patients presented with severe hypoxia (median PaO2/FIO2 ratio = 116), requiring advanced noninvasive ventilation (Venturi mask and continuous positive airway pressure) in the majority of cases. All patients were treated with hydroxychloroquine, azithromycin, and low-molecular-weight heparin at anticoagulant dose. Overall in-hospital mortality was 10% (1/10), peaking 25% in patients who developed COVID pneumonia immediately after CS. The remaining patients, with late infection, were all discharged home without oxygen support, at a median of 25 days after symptom onset.
As postoperative mortality in case of COVID pneumonia is not negligible, meticulous rules (precise triage, safe hospital path, high level of protection for health-care teams, prompt diagnosis of suspicious symptoms) should be strictly followed in patients undergoing CS during COVID pandemic. The role of therapies alternative to CS should be further assessed.
本研究旨在描述 COVID-19 大流行期间紧急心脏手术连续患者系列的临床过程。
在意大利，COVID 疫情主要发生在米兰大都市区和伦巴第大区周边地区，先前“常规”医院已转为 COVID 轮辐，以增加 ICU 床位供应，并仅允许进行紧急 CS 手术。
在紧急 CS 患者（左主干狭窄伴不稳定型心绞痛、急性心内膜炎、即将心力衰竭的瓣膜反流）中，10 例患者（平均年龄=57±9 岁）尽管入院分诊呈阴性，但在 CS 后 7 天中位数时发生 COVID 肺炎。
患者表现出典型的淋巴细胞减少症、更高的血栓前状态谱和更高的炎症标志物（铁蛋白和白细胞介素-6 值）。在肺窘迫的高峰期，患者表现出严重的低氧血症（中位数 PaO2/FIO2 比=116），需要在大多数情况下使用文丘里面罩和持续气道正压通气进行高级无创通气。所有患者均接受羟氯喹、阿奇霉素和低分子肝素抗凝剂量治疗。总体住院死亡率为 10%（10/10），CS 后立即发生 COVID 肺炎的患者死亡率最高达 25%。其余的患者，感染较晚，均无需吸氧出院，症状出现后中位数为 25 天。
由于 COVID 肺炎的术后死亡率不容忽视，因此在 COVID 大流行期间接受 CS 的患者应严格遵循细致的规则（精确分诊、安全的医院路径、为医疗保健团队提供高水平的保护、及时诊断可疑症状）。替代 CS 的治疗方法的作用应进一步评估。
