Introduction

The COVID-19 pandemic continues to impact patients and healthcare in the United States in ways that exceed initial expectations. There is a growing number of patients with a history of COVID-19 infection and concomitant cardiovascular disease who are now presenting for cardiac procedures. Multiple studies have shown that perioperative COVID-19 infection is associated with higher mortality rates and increased respiratory complications.1,2 This underscores the importance of delaying procedures for patients recovering from COVID-19. However, there are currently no established guidelines in the field of cardiac surgery regarding safe timelines for performing procedures on patients with a recent history of COVID-19. With additional evidence, such as elevated D-dimer levels, fibrinogen degradation products, and increased troponin markers in COVID-19 patients, COVID-19 is increasingly recognized as a cardiovascular disease.3 Establishing guidelines for a safe timeline to perform cardiac surgery in post-COVID-19 patients is crucial.

Methodology

This study employs a retrospective analysis of existing literature to develop guidelines for cardiac surgery in post-COVID-19 patients. The methodology involves a systematic review of published retrospective studies that focus on surgical outcomes in patients who have recovered from COVID-19. The goal is to identify key factors, patterns, and outcomes that should inform the development of guidelines for this specific patient population.

Data Sources

The data for this study were obtained from peer-reviewed articles published between 2020 and 2022. Databases such as PubMed, MEDLINE, and Cochrane Library were searched using the following keywords: “COVID-19,” “cardiac surgery,” “post-COVID-19 outcomes,” “guidelines,” “retrospective study,” “surgery”, and " complications." The review included studies such as Jonker et al. (2021), Doglietto et al. (2020), Zamboni (2020), Patel et al. (2020), Sanders et al. (2021), Ismail et al. (2022), Lei et al. (2020), and others that provided insights into the challenges and outcomes associated with surgery in post-COVID-19 patients.

Inclusion criteria

Studies involving adult patients (≥18 years) who underwent any form of surgery post-COVID-19 recovery. Studies published in English. Retrospective studies providing data on perioperative and postoperative outcomes. Studies that delineate the impact of COVID-19 on surgical outcomes.

Exclusion criteria

Studies involving pediatric patients. Studies not specific to surgery or those that do not focus on post-COVID-19 patients. Non-English studies and studies without full-text access.

Ethical Considerations

This study is based on secondary data analysis and does not involve direct patient interaction. As such, ethical approval was not required. However, all studies included in the review were conducted in accordance with ethical standards and obtained appropriate patient consent.

Discussion

Patients undergoing cardiac surgery represent a unique population during the COVID-19 era. This is due to the risk of exposure to others from highly invasive, aerosol-generating procedures, the potential for prolonged hospitalization or ICU stays, and the overall intense use of healthcare resources.4 Identifying patients who are COVID-19 positive before surgery is crucial because the use of a cardiopulmonary bypass machine can exacerbate the infection due to the systemic inflammatory response.4

Interestingly, Sanders et al. and Ismail et al. found that patients with a pre-operative COVID-19 diagnosis recovered similarly to non-COVID-19 patients after cardiac surgery.5 However, Sanders et al. did find an increased hospital length of stay by two days in the COVID-19 patients. They also found an increase in pulmonary complications when performing cardiac surgery on patients within twenty-four days of diagnosis.5

The primary concern with performing surgery within four weeks of a COVID-19 diagnosis is the increased risk of mortality and pulmonary complications. Recent evidence indicates that COVID- 19 patients undergoing surgery may be more prone to pneumonia and ARDS postoperatively, even if asymptomatic.6 Patients who had surgery less than six weeks after a COVID-19 diagnosis experienced significantly higher adjusted thirty-day postoperative pulmonary complication rates compared to those without COVID-19. This risk returns to baseline after seven weeks.7,8

Bryant et al. demonstrated an observed link between COVID-19 infection and postoperative cardiovascular complications, including conditions like deep vein thrombosis, pulmonary embolism, myocardial injury, and mortality within 30 days after surgery. The study accounted for race as a confounder, considering prior evidence of increased adverse event rates among minority groups following infection. Additionally, the study assessed outcomes based on vaccination status and whether COVID-19 patients exhibited symptoms or were asymptomatic.9

Among the patients included in the study, 34.9% underwent surgery within seven weeks of their confirmed COVID-19 diagnosis. The median time from diagnosis to surgery for the cohort was ninety-eight days. Within the patient group, 30.5% experienced cardiovascular morbidity outcomes, and there was a 2% mortality rate within 30 days following surgery.9

Extending the interval between a positive SARS-CoV-2 test and a subsequent procedure was associated with a reduction in the occurrence of postoperative adverse effects. This relationship persisted even when examining symptomatic patients at the time of their COVID- 19 diagnosis.9

El-Boghdadly et al. conducted a large multinational study involving over 100,000 patients across various surgical specialties. They found that elective surgery should be postponed for at least seven weeks following a COVID-19 diagnosis. This recommendation holds unless the risk of delaying the surgery outweighs the risk of postoperative morbidity and mortality associated with COVID-19.10

The American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation stated that the timing of elective surgery is crucial to consider. For patients who recently recovered from COVID-19, the decision to proceed with surgery should be based on the patient’s previous symptoms and their severity. The statement recommends waiting:

  • 4 weeks for asymptomatic patients or those with mild non-respiratory symptoms 6 weeks for symptomatic patients who were not hospitalized
  • 8 -10 weeks for symptomatic patients with diabetes, immunocompromised, or those who require hospitalization
  • 12 weeks for patients who needed ICU admission. 10

Conclusion

Cardiac surgery can be safely conducted in patients who have recovered from pre-operative COVID-19 infection, particularly those with asymptomatic to mild symptoms. Studies and guidelines recommend waiting at least 7 to 8 weeks before performing cardiac procedures in post-COVID-19 patients.9,10

Limitations

The data correlate with previous strains of COVID-19 and may not be applicable to current variants. Many studies were retrospective. Additionally, this research was conducted when vaccinations were still new, and the population had not yet achieved herd immunity. The outcomes could differ for vaccinated individuals who were infected with COVID-19 prior to surgery. Some guidelines are not cardiac-specific, though cardiac procedures were included in certain studies.