Topic: Heart Surgery: Operating the critically ill, Era of Covid

Speaker: Prof Dr Sujay Shad, Co-Chairman Cardiac Surgery, Sr Consultant Cardiac Surgeon, Director Heart-Lung Transplant, Sir Ganga Ram Hospital, New Delhi

• When Covid-19 surfaced two years back, it came as a surprise as we did not have a clue as to how to manage the evolving situation. While the harsh lockdown in the initial phase of the pandemic provided an opportunity to sort out masks and PPEs, hospitals more or less came to a standstill at that time.
• Papers on myocardial injury in patients who survived Covid were published. There was a panic that even people who did not have apparent cardiac illness are suffering from some myocardial damage due to fibrosis visible on MRI.
• Cardiac surgery was also reduced partly because of the lockdown and partly because of the rest and relaxation, stress which precipitated MI also reduced.
• Mechanisms for myocardial injury in Covid-19 include direct ACE-mediated viral damage, exaggerated immune response causing hypoxic injury, microthrombosis and systemic inflammatory injury.
• The hyperinflammatory response phase was followed by recovery phase in the majority. Lung damage was important in the initial phase.
• There were multiple issues along the cardiopulmonary axis. On MRI, there were pulmonary infiltrates/effusion and respiratory failure in suspected acute Covid-19 myocarditis. There was some left ventricle dysfunction, stress-induced cardiomyopathy, which could have contributed to the failing lungs. Diffuse myocardial edema on T2 weighted scans and hyperemia as early gadolinium enhancement was also seen. Overtime, there was lot of fibrosis in the form of necrosis/scar identified with late gadolinium enhancement.
• Emergency cases like aortic dissection, hemodynamic instability or patients whose symptoms are worsening underwent surgery, but there were lot of problems in these patients. The most important problem in these patients was persistent hypoxia postoperatively and persistent vasoplegic syndrome after the surgery.
• Elective work like valve repair for asymptomatic valvular disease was stopped completely and postponed if the patient stayed comfortable.
• Semi-elective patients were turned into elective wherever possible. Some patients underwent stenting to bypass the bypass surgery.
• A persistent requirement of vasoconstrictors and inotropes in substantial doses was observed in Covid patients, which lasted for as many as 5 days. This was seen even in patients who had mild Covid-19.
• It is important to understand the reasons for postponing cardiac surgery. The average mortality in patients with an active SARS-CoV-2 infection ranged from 20% to 41%. The incidence of myocardial injury has been reported to be more than 25% of critically ill Covid patients. 
• Nasal swabs or antibody tests for seroconversion were used to determine Covid status. In inconclusive cases, Ct value was used. Surgery could reasonably be done in asymptomatic patients with high Ct value. Patients with CRP five times above normal could be operated. But surgeries in patients with very high CRP levels were postponed.
• Various postoperative complications included increased ventilator assistance time, length of ICU stay, atelectasis, pulmonary edema, GI dysfunction, acute renal injury, coagulation disorders, atrial arrhythmia etc. 
• At one year, patients who were not hospitalized tended to do much better than those who were hospitalized. Cerebrovascular disorders, dysrhythmias, and other cardiac disorders such as heart failure, ischemic cardimyopathy, cardiac arrest, cardiogenic shock, PE, DVT, superficial vein thrombosis occurred in these patients.
• The alpha wave could be side stepped because of the lockdown, but the delta wave hit really hard. Majority of ECMOs that took place in India were during the delta wave.
• Some centers recommended ECMO early for patients who went from HFNO to ventilators, while some patients were directly shifted to ECMO without going through the ventilator.
• This was also the time when there was shortage of hospital/ICU beds, oxygen including hospital staff. The mortality with ECMO therapy in the best of centers was 37-60%. In India, only 10-15% of patients on ECMO could be salvaged.

COVID-19 Update

Speaker: Dr Monica Vasudev, Allergist & Clinical Immunologist, Fellow of American

Academy of Asthma, Allergy and Immunology, Advocate Aurora Health, Wisconsin, USA

• Global deaths have crossed six million. We are seeing a long tail of the pandemic and we cannot let down our guard.
• Surveillance of waste water in the US has shown that there was an increase in the amount of virus shedding in the first two weeks of March. More than one-third of places monitoring this showed a rising Covid-19 trend.
• There is still a need to continue to reinforce the benefits of immunization.
• Moderna and Pfizer have requested authorization from the FDA for second boosters of their Covid vaccines. These requests were partly based on data from Israel, after the emergence of Omicron variant that showed a second booster dose reduces the infection rates as well as severe illness.
• A study in JAMA Neurology has reported that cognitive impairment was more common in older Covid patients aged ≥60 years, especially those with severe illness after discharge from hospitals vs their uninfected peers.
• Children have low levels of antibodies. They have similar symptoms and levels of virus, but they seem to be able to clear the virus from their bodies much quicker than adults due to a more robust initial immune response. Its to be seen how well children are protected against future infections. 
• About 1.6 billion children globally have been affected by the closure of schools due to the pandemic. Children in the low- and middle-income countries have been disproportionately affected as their schools tended to be shut for longer and they were less able to access remote learning.
• According to UN Education expert, Robert Jenkins, “we are running the risk of a lost generation… Without urgent action, many countries could end up without the skilled workers they need for future development.”

Hong Kong Update

Speaker: Dr Alvin Yee-Shing Chan, Treasurer, CMAAO

• The situation is not so good in Hong Kong. The current wave is the fifth wave.
• About 91.5% population is vaccinated with the first dose and nearly 82% are vaccinated with the second dose. So, about 19% of population has not yet received the second dose.
• There is high infection rate and mortality rate right now especially in the elderly above 80 years of age; only half of this population is vaccinated. Even in ≥70 years age group, less than 80% are vaccinated.
• There are around 200 deaths in a day, most of them are in the elderly and immunocompromised. The mortality rate is 0.5%.
• 56% of young children (3-11 age group) are vaccinated with the first dose and 8% have been vaccinated with the second dose.
• It is hoped that 95% of the population would be vaccinated by early April.
• There are not enough isolation or hospital facilities. Daily cases were earlier around 30,000 but in the last two days have reduced to 2000 per day.
• There are hidden cases as it is not mandatory to report the results of self-testing.
• Sewage water is being tested. If positive, then the building is put under lockdown and all residents are tested.
• Paxlovid and molnupiravir are now available in public hospitals and designated Covid clinics, but these are not yet available in the private sector.

 Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair of Council CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO

Dr Marthanda Pillai, India Member World Medical Council, Advisor CMAAO

Dr Heidi Stensmyren, President, World Medical Association

Dr Ravi Naidu, Malaysia

Dr Mvuyisi Mzukwa, South Africa

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Sonam Tshering, Bhutan

Dr Qaiser Sajjad, Pakistan 

Dr Ashraf Nizami, Pakistan

Dr Salma Kundi, Pakistan

Dr Md Jamaluddin Chowdhury, Bangladesh 

Invitees

Dr Monica Vasudev

Dr Sujay Shad 

Dr Patricia La’Brooyi

Dr Lawrence HB Soh

Dr Khoonhui Yeo

Dr Stephen Chang

Dr Ng hong Yi

Dr Joshua Lim

Dr Sanjeev Aggarwal

Dr Kuenza Wangmo

Dr Colin Goldberg

Dr Kiran Vinayek

Dr Manisha Kukreja

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal