ABSTRACT
Objective Previous studies reported unfavorable results in COVID-19 patients who underwent cardiac surgery. Complications most frequently observed were respiratory failure and higher incidence of thromboembolic events. We present our single-center experience in patients with perioperative diagnosis of COVID-19 infection undergoing cardiac surgery with extracorporeal circulation. Methods In this observational matched case-control (propensity match 1:2) study, we collected data of patients undergoing open heart cardiac surgery from January 2020 to May 2021, having positive perioperative diagnosis of COVID-19 infection confirmed by polymerase Chain Reaction-PCR (study group). Patients were compared with 56 corresponding controls (control group) who matched for age, sex, body mass index (BMI) and Euro-Score II. Results In the study period 1060 patients underwent cardiac surgery with cardiopulmonary bypass (CPB). Among them, 28 consecutive patients, aged 70.1±9.3 years, had perioperative diagnosis of COVID-19 infection. Four (14%) patients underwent emergency surgery for type-A aortic dissection, 2 (7%) patients died in the Intensive Care Unit for severe respiratory failure, shock and multiple organ failure. Significant bleeding complications occurred in 14 (50%) patients in the study group (vs 6% in the control group, p=<0.05). In the study group, 11 (39%) patients required early surgical reexploration for bleeding, 5 presented cardiac tamponade, 5 (18%) underwent multiple surgical revisions for recurrent bleeding. Three (11%) patients required late chest drainage of a massive sero-hemorrhagic pleural effusion, 1 (4%) presented late postoperative intracranial hemorrhage. Fourteen (50%) patients had severe thrombocytopenia (vs 9% in the control group, p=<0.05). In the study group blood components transfusion and procoagulant drugs administration increased (79% and 78% vs 18% and 11% in the control group, respectively, p=<0.05). In the study group 6 (21%) patients presented postoperative acute renal failure (2% in the control group, p=<0.05), 7 (25%) acute respiratory failure (p=<0.05) requiring prolonged postoperative orotracheal intubation. Sternal dehiscence was observed in 4 (14%) patients in the study group (vs 4% in the control group, p=< 0.05). Complications significantly influenced hospital stay length (20 ± 3.1 vs 8.1 ± 3.9 days, p=< 0.05). In the multivariable logistic regression model the SARS-CoV-2 infection and renal failure were independent factors associated with severe postoperative complications (p=<0.01). Conclusions Clinical outcome of open heart cardiac surgery patients with perioperative COVID-19 infection appears significantly impaired in terms of mortality and postoperative complications. CPB-related inflammatory reaction could likely exacerbate the deleterious effect of COVID-19 on the respiratory and renal systems, as well as on the coagulation pathways. Early and late hemorrhagic complications were very frequent with significantly increased surgical reexplorations for bleeding, a higher incidence of severe thrombocytopenia, of blood components transfusion and procoagulant drugs administration. The increased surgical risk should suggest a cautious attitude in indicating open heart surgery in patients with perioperative COVID-19 infection and surgery should be limited to not postponable or to urgent cases.
ABSTRACT
OBJECTIVE: Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients. DESIGN: Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection. SETTING: Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area. PARTICIPANTS: In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score. INTERVENTIONS: Open-heart cardiac surgery on CPB. MEASUREMENTS AND MAIN RESULTS: In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively). CONCLUSIONS: A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.