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\begin{document}

\title{The Impact of COVID-19 on Surgery and Procedures:~ A Commentary}



\author[1]{Frank Annie}%
\author[1]{Jaineet Singh Chhabra}%
\author[1]{Aravinda Nanjundappa}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 24, 2024}


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The Impact of COVID-19 on Surgery and Procedures: A Commentary

Frank H Annie, PhD\textsuperscript{1}; Jaineet Singh
Chhabra\textsuperscript{3}; Aravinda Nanjundappa, MD\textsuperscript{2};

\textsuperscript{1}CAMC Health Education and Research Institute

3200 MacCorkle Ave. SE, Charleston, WV 25304.

\textsuperscript{2}CAMC Vascular Center of Excellence, Charleston Area
Medical Center.

3200 MacCorkle Ave SE, Charleston, WV 25304

\textsuperscript{3}Marshall University, School of Medicine.

1600 Medical Center Dr, Huntington, WV 25701

\emph{Study Locations:}

Charleston Area Medical Center, 3100 McCorkle Ave SE, Charleston, WV,
25302 and Charleston Area Medical Center Research Institute and Center
for Clinical Sciences Research, 3200 McCorkle Ave SE, Charleston, WV,
25302

\emph{Correspondence:}

Frank Annie M.A; MPA, PhD

Research Scientist

CAMC Health Education and Research Institute

3200 MacCorkle Ave. SE,

Charleston, WV 25304

Phone 304-388-9921

Fax: 304-388-9921

Email:\emph{Frank.H.Annie@camc.org}

\emph{Total word count:} 1317

\emph{Author Disclosure Block:} None

\emph{Key words:} NA

\emph{Running Title: NA}

\emph{Total Number of Tables and Figures: NA}

\textbf{Background}

Originating in Wuhan, China at the end of 2019, Coronavirus 2019
(COVID-19) is a disease caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (1). The World Health Organization (WHO)
first characterized COVID-19 as a pandemic on March 11, 2020 to promote
the need for better detection and spread containment internationally
(2). Healthcare facilities across the United States (U.S.) are
significantly changing their operations to protect patients and
employees from exposure, including use of telehealth communication for
triage, assessment, and care for patients with mild illnesses (3). For
emergency cases, the American College of Surgeons (ACS) recommend lead
physicians and administrators organize alternative measures in response
to trauma, cardiac, and stroke systems reaching full capacity when
possible (4). While practice of social distancing is currently the best
way to prevent overload of our healthcare system and protect our
employees (5), the ACS, in compliance with CDC guidelines (6), gently
reminds us that postponement of elective surgeries or procedures may
eventually prompt emergent cases due to disease progression (7). When
elective cases and procedures become emergent, non-deferrable
interventions require strict adjustment of hospital protocol. Aside from
minimization of contact and appropriate use of personal protective
equipment (PPE) during mass casualty incident (MCI) response, major
Italian surgical and anesthesiologic societies emphasize the need of
segregation of COVID-19 and non-COVID-19 patients requiring surgery
along with careful monitoring of resource usage such as staff, intensive
care beds, material, and device conservation (8).

Singapore General Hospital, a large tertiary level acute care center,
implemented some these disaster measures before Coccolini et al.
published their insights. They divided surgical staff members, including
on-call anesthesiologists, into two groups, in which one exclusively
cared for patients infected or suspected to be infected with COVID-19
while the other group managed treatment for non-COVID-19 patients. They
also postponed non-urgent preoperative assessment clinic visits,
relocated elective surgeries for non-COVID-19 patients to their main
operating room (OR) complex away from three smaller ORs housing COVID-19
cases, switched to stricter sanitary practices, and ran \emph{in
situ}simulations to prepare for unexpecting problems during crisis. With
repetition, team members comprising various surgical disciplines
improved their ability to address situational problems including
scenarios involving infection control breaches and unsatisfactory
equipment set-up (9). In accord with Singapore General Hospital, there
are other organizations that aim to use their experiences with COVID-19
to create a system that best addresses the needs of all patients
requiring procedural or surgical intervention. The Asian Pacific Society
for Digestive Endoscopy affirms that deferment of elective procedures,
such as non-emergent endoscopies, is essential to prevent further
spread. However, they suggest that semi-urgent procedures be reviewed on
a case by case basis (10). In collaboration with Asian and European
Organizations, major departments of Otolaryngology across the U.S. are
making strong efforts to emulate the strict safety guidelines employed
by centers in Singapore and Hong Kong when considering intervention for
patients who are not necessarily in need of emergent treatment (11).

Just prior to the COVID-19 pandemic declaration, evidence from China
indicated case fatality rates in patients with preexisting comorbid
conditions at 5.6\% for cancer, 6.0\% for hypertension, 6.3\% for
chronic respiratory disease, 7.3\% for diabetes, and 10.5\% for
cardiovascular disease (CVD) (12). Though COVID-19 is greatly associated
with respiratory illness (13) in elderly patients (14), the impact of
this virus on hypertension and cardiovascular disease (CVD) also
requires significant attention given that SARS-CoV-2 infects host cells
via angiotensin-converting enzyme 2 (ACE2) receptors. These receptors
are highly expressed in both the lungs and heart (15). Considering the
role of ACE2 in SARS-CoV-2 entry, there is much debate whether
angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin
receptor blockers (ARBs) should be administered to hypertensive
patients. However, there is currently little evidence that clearly shows
whether ACEIs/ARBs inhibit ACE2 or upregulate it. Major organizations,
including the American College of Cardiology (ACC) and the European
Society of Cardiology, strongly recommend that physicians continue
giving ACEIs/ARBs per standard protocol until further investigations
suggest otherwise (16,17). The ACC also cites the need for further
investigation to determine the impact of COVID-19 on CVD-na\selectlanguage{ngerman}ïve patients
that were otherwise healthy prior to infection (18). Though preoperative
administration of ACEIs/ARBs remains the same, delaying surgery for
non-COVID-19 and COVID-19 patients with chronic hypertension may
negatively affect their care due to a highly individualized treatment
regimen (19) that could be further complicated by disease progression.

In addition to the possible impact of COVID-19 on blood pressure
management, its negative effects on patients with underlying CVD,
potential cause of acute myocardial injury (20), and facilitation of the
FDA's approval for use of extracorporeal membrane oxygenation (ECMO) in
lieu of ventilators (21) pose great challenges for healthcare staff
involved in cardiovascular care. The ACC and Society for Cardiovascular
Angiography and Interventions (SCAI), in accord with other disciplines,
recognizes that teams, including cardiac surgeons, interventional
cardiologists, and anesthesiologists, must make difficult decisions
regarding whether they should proceed with scheduled valvular or
structural interventions. The ACC/SCAI advise teams move forward on a
case by case basis (22). For example, it is currently reasonable to
postpone scheduled transcatheter aortic valve replacement (TAVR)
procedures for asymptomatic patients with severe aortic stenosis while
monitoring them via telehealth communications as opposed to delaying
intervention for symptomatic patients who are at high risk of clinical
deterioration, prolonged hospital stay, or repeat hospitalization.
Complexity becomes increasingly apparent, however, when considering
symptomatic TAVR candidates who could also benefit from percutaneous
coronary intervention (PCI). Per the ACC/SCAI consensus statement, PCI
scheduled or recommended for symptomatic TAVR candidates before
implantation of their new aortic valve should be deferred unless
coronary artery disease (CAD) is affecting clinical presentation. Those
on the front lines in Italy agree that comprehensive cardiovascular care
need be multifaceted and integrative (23), suggesting that
multidisciplinary organization and collaborative preparedness will help
us better manage patients with CVD.

The COVID-19 Guidelines for Triage of Vascular Surgery Patients
established by the ACS do provide some direction regarding non-emergent
cases, such as allowing a surgeon to exercise judgment when considering
repair of an abdominal aortic aneurysm (AAA) \textgreater{} 6.5 cm or
revascularization for a high grade restenosis stemming from previous
intervention (24). Though elective cases must be postponed, vascular
department heads worldwide are collaborating on safe surgical and
procedural measures for patients requiring non-emergent, as well as
emergent, care. Vascular surgery leadership at Walter Reed National
Military Medical Center conveys the importance of forming international
partnerships, calling attention to how the U.S. military drew on the
experiences of other nations and amassed their support to handle the
crisis that took place on 9/11/2001 (25). The aforementioned safety
measures that some health centers in Singapore are taking extend to
their vascular surgery departments. Emulation of their team segregation
practices, excellent use of telehealth, and resource conservation (26)
will possibly better enable U.S. health systems to keep workers and
patients safe while addressing gray areas related to elective surgery
cancellations.

There is proposal of using some ambulatory surgery facilities, due to
their closure, for resource contribution that may partially relieve the
current strain on our healthcare system (27). Though additional evidence
is needed to elucidate special safety measures and confirm the overall
benefit of this suggestion, improved resource distribution may help U.S.
organizations provide broader care without ignoring the situation at
hand. Delaying interventions, especially for patients with vascular
and/or structural heart disease, enables worsening of minor to moderate
conditions. Additional evidence is necessary for determining how we can
safely treat both non-COVID-19 and COVID-19 patients requiring surgeries
or procedures during this pandemic, as cancellation of elective
interventions may have larger implications than minor inconveniences.
Literature citing association between past receipt or donation of organs
and negative outcomes stemming from SARS-CoV-2 are also lacking (28).
Along with provision of multidisciplinary care for COVID-19 patients and
the importance of adjusting to constantly evolving information, it is
crucial for us to remember that there are non-infected persons with
progressive diseases directly suffering from this crisis as well.

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