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\begin{document}

\title{The Pan London Emergency Cardiac Surgery Service Blueprint}



\author[1]{Daniel  Fudulu}%
\author[2]{Gianni Angelini}%
\author[1]{Hunaid Vohra}%
\affil[1]{Bristol Heart Institute}%
\affil[2]{Bristol University}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\begin{abstract}
The authors share their experience of managing the cardiac surgery
services across London during the challenging Covid-19 pandemic. The Pan
London Emergency Cardiac Surgery Service model could serve as a
blueprint to design policies applicable to other surgical specialities
and parts of the UK and worldwide.%
\end{abstract}%



\sloppy


\textbf{Abstract}

The authors share their experience of managing the cardiac surgery
services across London during the challenging Covid-19 pandemic. The Pan
London Emergency Cardiac Surgery Service model could serve as a
blueprint to design policies applicable to other surgical specialities
and parts of the UK and worldwide.

Hussain et al. \textsuperscript{1} must be congratulated on setting up
of the Pan London Emergency Cardiac Surgery Service PLECS in managing
cardiac surgical patients during the unprecedented Covid-19 crisis.
Undoubtedly, the speciality of cardiac surgery in London is in a unique
position to develop such a protocol since London is one of the most
affected and challenged cities in the world from the outset,
contributing predominantly to Covid-19-related UK mortality which is the
highest in Europe\textsuperscript{2}. The graph for the number of people
infected with Covid-19 admitted to a UK hospital reached its peak in the
early April\textsuperscript{3}. As of 18\textsuperscript{th} of May,
London still leads with a total of 26440 confirmed Covid-19
cases\textsuperscript{4}. One of the critical strategies for managing
such a public health emergency is careful containment. Therefore, the
designation of Covid-free hospitals (``delivery units'') that could
perform cardiac surgery in a safe environment is paramount. Hence,
centralisation of the cardiac surgery services from seven to two units
with minimal Covid-19 contamination that could deal with London cardiac
surgery pool of patients was one of the primary measures reported by the
authors. Indeed, London is the only city in the UK which has the
privilege to take such a step due to the number of cardiac units,
manpower provision, resource allocation and transport infrastructure.
However, the disruption of the ample provision of the above resources
available normally, could, on the contrary, lead to worse chaos in a
pandemic crisis in a city like London.

Maintenance of a Covid-19 free environment is equally important. This
has now become an integral part of all decision tree algorithms
throughout the world\textsuperscript{5}. Broadly, this requires clinical
screening and a Covid-19 nasopharyngeal swab test before and after the
transfer of the patient for urgent and emergency surgery. Recently
published national guidance\textsuperscript{6} suggests that computer
tomography for screening for Covid-19 in elective patients (this would
include urgent patients admitted from home with
critical/life-threatening anatomy with worsening symptoms or the need
for prognostic intervention) is not routinely recommended and should
only be reserved for urgent or emergency cases. One can imagine that the
breakout of Covid-19 in these two cardiac surgical units would lead to
disastrous consequences. It is widely believed that patients with
Covid-19 who undergo cardiac surgery have significantly higher morbidity
and mortality. A retrospective cohort study of 34 elective general
surgical operations on patients with confirmed Covid-19, 44.1\% of
patients, needed ICU care, and the mortality rate was
20.5\%\textsuperscript{7}.

It was with great regret that we recently learned about the demise of
two UK cardiac surgeons with Covid-19. Incentives like the PLECS
referral pathway have led to a heightened awareness of Covid-19 risk of
infection in cardiac surgical practice in a relatively short time
period. Such algorithms ensure health care worker safety but also can
inform decision making when taking a patient for surgery.

The current article also highlights the need for hospitals to adopt
theatre specific pathways with the assumption that all patients are
Covid-19 positive despite a negative swab (false
negative)\textsuperscript{5,8}. While appropriate theatre personal
protective equipment (PPE) is vital to ensure staff and patients safety,
performing heart operations with full PPE (including respirator hoods)
can be difficult and is associated with difficult vision, headaches,
inadequate hearing/communication, facial pain and dry throat. This,
along with the sheer nature of these advanced cardiac patients (older
patients, critical disease, ongoing symptoms, hypertrophic and impaired
left ventricle, emergency), makes cardiac surgery a challenging venture.
Leadership based on hierarchical command is essential during such a
crisis, akin to a war situation. The establishment of a command centre
that uniquely coordinates cardiac surgical activity in the whole of
London accordingly between the delivery unit and ``referring'' unit is
of paramount significance for the smooth running of a crucial service in
the capital. Many units throughout the UK have now adopted a Covid-19
central command hub similar to the one presented by the authors, mainly
for Covid-19 in general. To assist in the allocation and timing of
appropriate procedures, all cardiac surgical departments in the UK have
embraced the concept of regular as well as adhoc multidisciplinary team
meetings with the help of online conference tools. To avoid cardiac
surgery-associated Covid-19 morbidity and mortality, TAVI or PCI is the
recommended option if it is considered a reasonable treatment but not
the usual recommended treatment as dictated by the best evidence. This
would also avoid death on the surgical waiting list and minimise the
burden on critical care.

Coming out of this pandemic, the focus will be on the need for risk
stratifying patients referred for surgery and those on the already
prolonged waiting list. Step-wise guidance for return of services
dealing with cardiovascular diseases in North America has already been
published\textsuperscript{9}. It is estimated that 28,404,603 elective
operations would have been cancelled worldwide during a 12-week peak
disruption during the pandemic. Intelligent and sensible triaging of
patients waiting to undergo cardiac surgery will test our leadership
during a period of already pressurised health service. The usefulness
PLECS Service model will be instrumental in serving as a blueprint to
design policies applicable to other surgical specialities and parts of
the UK and worldwide. However, due to the differing landscape of other
UK cities, the PLECS model may not be entirely reproducible as in London
and will have to be adapted to the regional characteristics. It would be
of great interest to determine the characteristics, volume and outcomes
of patients who have undergone urgent and emergency cardiac surgery
under the PLEC service and a publication in this regard would be eagerly
awaited.

\textbf{References:}

1. Hussain A, Damian B, Martin Y, et al. The Pan London Emergency
Cardiac Surgery Service: Coordinating 4 a response to the COVID-19
pandemic. \emph{Journal Card Surg (in press)} . 2020.

2. WHO Coronavirus Disease (COVID-19) Dashboard.
https://covid19.who.int/. Accessed May 20, 2020.

3. Prime Minister's Office 10 Downing Street. \emph{Slides to Accompany
Coronavirus Press Conference: 30 April 2020} .; 2020.
https://www.gov.uk/government/publications/slides-and-datasets-to-accompany-coronavirus-press-conference-30-april-2020.

4. Coronavirus (COVID-19) in the UK.
https://coronavirus.data.gov.uk/\#category=regions\&map=rate. Accessed
May 18, 2020.

5. Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for
Operating Room Team Members During the COVID-19 Pandemic. \emph{J Am
Coll Surg} . 2020. doi:10.1016/j.jamcollsurg.2020.03.030

6. \emph{Current Recommendations Regarding Pre-Operative COVID-19
Screening CT Scan in Patients Undergoing Cardiothoracic Surgery} .;
2020. https://scts.org/covid-19/.

7. Nepogodiev D, Bhangu A. Elective surgery cancellations due to the
COVID-19 pandemic: global predictive modelling to inform surgical
recovery plans. \emph{Br J Surg} . May 2020. doi:10.1002/bjs.11746

8. \emph{SCTS/ACTACC/SCPS Theatre COVID Pathway} .; 2020.
https://scts.org/wp-content/uploads/2020/03/SCTS-ACTACC-SCPS-Theatre-COVID-pathway-Final.pdf.

9. Virani A, Poppas A, Russo M, et al. Safe Reintroduction of
Cardiovascular Services during the COVID-19 Pandemic: Guidance from
North American Societies. \emph{Can J Cardiol} . 2020.
doi:10.1016/j.cjca.2020.04.031

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