Considering Coronary Artery Bypass Grafting in COVID-19 Patients
Authors: Zain Khalpey, MD, PhD, FACS, Parker Wilson, BS, Ezekiel Mendoza, BS, Amina Khalpey, PhD
The COVID-19 pandemic has changed the medical community in unprecedented ways. One of the major challenges faced by cardiac surgeons during this pandemic was performing coronary artery bypass grafting (CABG) in COVID-19 positive patients. CABG is a common surgical procedure used to treat symptomatic coronary artery disease (CAD) and involves bypassing blocked or narrowed coronary arteries with grafts to restore blood flow to the heart. In this essay, we will discuss the safety of CABG in asymptomatic vs symptomatic COVID-19 positive patients, the potential complications, and hybrid strategies that can be used to help these patients. Lessons learned in these patients will be used throughout the future when we encounter future viral outbreaks, including the yearly influenza epidemics.
Complications are Prevalent
The safety of CABG in COVID-19 positive patients was a topic of debate among cardiac surgeons. A 2021 meta-analysis of 58 studies with a total of 12,376 COVID-19 positive patients undergoing surgical procedures found that the overall mortality rate was 21.6% (Liang et al., 2021). However, the mortality rate varied depending on the type of surgery performed, with cardiac surgery having a lower mortality rate of 7.6% compared to non-cardiac surgery (Liang et al., 2021).
Several studies have reported that COVID-19 positive patients who undergo CABG have a higher risk of morbidity and mortality compared to COVID-19 negative patients undergoing the same procedure (Kassem et al., 2021; Salenger et al., 2020). A study by Kassem et al found that COVID-19 positive patients undergoing CABG had a higher incidence of postoperative complications, including acute respiratory distress syndrome (ARDS), renal failure, and sepsis, compared to COVID-19 negative patients. Additionally, COVID-19 positive patients had a longer hospital stay and higher mortality rate compared to COVID-19 negative patients (Kassem et al., 2021).
COVID-19 positive patients undergoing CABG are at higher risk of complications compared to COVID-19 negative patients. One of the major complications reported in COVID-19 positive patients undergoing CABG is ARDS, which is a severe respiratory complication that can lead to respiratory failure and death (Salenger et al., 2020). Other complications reported in COVID-19 positive patients undergoing CABG include myocardial infarction (MI), stroke, acute kidney injury (AKI) and renal failure, and even sepsis (Kassem et al., 2021).
These data should give us pause when caring for COVID-19 patients as well as patients with other respiratory illnesses. These patients are in a precarious, pro-inflammatory state that lends itself to developing devastating post-operative complications, such as AKI and MI. It is therefore important to exercise caution when caring for these patients in the perioperative period, ensuring adequate hydration, oxygenation, anticoagulation and monitoring.
Hybrid strategies for CABG in COVID-19 positive patients:
Given the higher risk of complications in COVID-19 positive patients undergoing CABG, several hybrid strategies have been proposed to help these patients. One such strategy is the use of extracorporeal membrane oxygenation (ECMO) during CABG. ECMO is a technique used to provide temporary respiratory and cardiac support to patients with severe respiratory and/or cardiac failure. In the beginnings of the COVID-19 pandemic, Zeng et al. (2021) reported successful outcomes in three COVID-19 positive patients undergoing CABG with ECMO support. Many patients from 2019 to present have survived devastating complications from the SARS-CoV2 virus due to ECMO (Bertini et al 2022).
Another strategy is the use of a minimally invasive approach to CABG. Minimally invasive CABG (MIDCAB) is avoids the traditional open chest approach to CABG and uses small incisions in the chest, minimizing exposure of the thoracic organs to open air in hopes of reducing post-operative complications. Generally, MIDCAB is reserved for frail patients who would not tolerate traditional CABG, but also may only have one diseased artery (Santavy et al 2013). MIDCAB has been shown to have lower morbidity and mortality rates compared to traditional CABG, making it an attractive option for COVID-19 positive patients (Jarral et al., 2020).
In conclusion, CABG in COVID-19 positive patients is associated with higher morbidity and mortality rates compared to COVID-19 negative patients. The potential complications of CABG in COVID-19 positive patients include ARDS, MI, stroke, AKI, renal failure, and sepsis. These should be reduced as much as possible in order to best care for these patients. There are several hybrid strategies that can be used to help these patients, including ECMO support during CABG and MICAB. These strategies may help reduce the risk of complications and improve outcomes for COVID-19 positive patients undergoing CABG. These same lessons can and should be applied to patients with other respiratory illnesses like influenza because these patients also are in a pro-inflammatory state that predisposes them to the same complications as COVID-19 patients.
It is important to note that the decision to perform CABG in COVID-19 positive patients should be made on a case-by-case basis. The risk-benefit ratio should be carefully considered, taking into account the patient’s individual characteristics, the severity of the CAD, and the extent of the COVID-19 infection. In some cases, the benefits of CABG may outweigh the risks, while in others, conservative management may be a better option.
Additionally, strict measures must be taken to prevent the spread of COVID-19 in the hospital setting, including preoperative screening, isolation protocols, and appropriate use of personal protective equipment (PPE). These measures can help reduce the risk of transmission of COVID-19 to healthcare workers and other patients.
Overall, CABG in COVID-19 positive patients remains a challenging clinical scenario. Further research is needed to identify optimal strategies to improve outcomes for these patients. In the meantime, cardiac surgeons must carefully weigh the risks and benefits of CABG and consider the use of hybrid strategies to help minimize the risk of complications.
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