COVID-19 Disruption of Pediatric Cardiac Surgery Services in Low and Middle Income Countries

Introduction
The COVID-19 pandemic has affected the delivery of cardiac surgery services around the world, and specific guidelines have been published in specialty journals regarding how to manage critical and noncritical patients with congenital heart disease during these trying times (1).

While the vast majority of total cases and the highest case fatality ratios have been circumscribed to wealthy countries, it is not known how low and middle income countries (LMIC) lacking excess-capacity buildup in their healthcare systems are managing the delivery of pediatric cardiac surgery.

Methods
To answer that question, the authors distributed a survey via email among a number of pediatric cardiac surgery centers located in several LMICs. The survey results appear in Table 1. Responses were anonymized, recorded, and aggregated.

Table 1. Countries surveyed/responded (58/35= 60.3%)

Results
The authors obtained responses from 69 centers (a 67% response rate) in 35 LMICs (a 61.4% response rate) distributed among five continents. Nearly 95.7% (n=66) of the centers have been directly impacted on their surgical volume by the pandemic, with 88.4% (n=61) ordered to halt all but essential operations by hospital, local, or national authorities.

Orders to stop nonemergency surgeries were issued as early as November (n=1), January (n=1), February (n=4), or March (n=55). Eight centers never received such orders. At the time of this survey (May 2-10, 2020), these orders continued in place in 68% (n=47) of the centers with half (n=34) of the centers expecting to be fully functional by June 1, 2020.

Preoperatively testing for COVID-19 is practiced in 51% (n=35) of centers and surgery for critical congenital heart disease has continued uninterrupted throughout the pandemic in 56 (81%) centers, while 13 (19%) have discontinued all surgeries.

According to the own estimates of the centers surveyed, about 29% (n=20) will lose more than 100 cases compared to 2019, 26% (n=18) will perform between 51–100 less, and 33% (n=23) will lose 20 to 50 surgeries this year. In all, anywhere to 3378 to 5450 cases are lost in 2020 by 61 centers, with eight centers reporting no losses in volume due to the pandemic (Figure 1).

Figure 1

As in wealthier health systems, social distancing in the form of videoconferencing has been implemented in 62% of centers (n=43), with only a small number of them (n=5) able or willing to afford encrypted data systems. Prostaglandin E1 availability was disrupted in 23% (n=16) of centers. While 38 centers provide ECMO services, one third of them have seen disruption in ECMO availability due to Covid-19.

Conclusions
The provision of normal pediatric cardiac surgery services in LMICs, as in wealthier nations, has been largely disrupted during the COVID-19 pandemic. The main difference resides in the potential loss of life among critical congenital heart disease patients in centers that stop surgery completely. As the back-log of non-emergent cases continues to collect (2), countries lacking excess capacity in their health systems are likely to suffer further disruptions. These conditions added to the known parent’s fears of going to the hospital for regular cardiology visits might result in an unusually high number of deaths in the months to come.

References

1. Stephens EH, Dearani JA, Guleserian KJ, Backer CL, Romano JC, Bacha E, et al. Covid-19: crisis management in congenital heart surgery. J Thorac Cardiovasc Surg. 2020 Apr.
2. Salenger R, Etchill EW, Ad N, Matthew T, Alejo D, Whitman G, et al. The surge after the surge: cardiac surgery post-COVID-19. Ann Thorac Surg. 2020 May 3;S000003-4975(20):30693-30697.

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