The modality of repeat revascularization due to late graft failure is a debatedtopic. The latest available European guidelines recommend redo coronary arterybypass graft (CABG) for cases of extensively diseased and/or occluded grafts andthose with diffuse native vessel disease. We present the case of a patient beingrelieved of recurrent unstable angina pectoris with redo CABG using no-touchsaphenous vein grafts after repeated and unsuccessful attempts with percutaneouscoronary intervention (PCI). This could be an alternative to PCI in patientswith a complex medical history. Teamwork between cardiologists and surgeons ispivotal in deciding the best treatment modality. We present the case of a patientbeing relieved of recurrent unstable angina pectoris following redo CABG usingno-touch saphenous vein grafts after repeated and unsuccessful attempts withPCI.Repeat revascularization due to late graft failure is a debated topic. Limited datafrom previous studies leave clinicians to decide between redo coronary artery bypassgraft (CABG) and percutaneous coronary intervention (PCI). The latest availableguidelines from the European Society of Cardiology and the European Association ofCardiothoracic Surgeons recommend redo CABG for cases of extensively diseased and/oroccluded grafts and those with diffuse native vessel diseaseThis case is about a 71-year old male with a previous history of type 1 diabetesmellitus complicated with blindness. He also suffered from chronic renal failure andperipheral arterial disease, resulting in toe amputations.. The patient received a no-touch SVG to the left anteriordescending artery (graft flow of 60 ml/min) and a sequential no-touch SVG to anintermediate artery and a marginal artery (graft flow of 65 ml/min), as well as ano-touch SVG implanted to the posterior descending artery (PDA) (graft flow of 27ml/min).In 1990, at age 41, he underwent CABG surgery due to angina pectoris and received asaphenous vein graft (SVG) to the right coronary artery (RCA) and the left internalthoracic artery to the left anterior descending artery. Until 2010 he was relievedof angina pectoris. Between 2010 and 2017, due to recurrent angina pectoris, sevenPCI procedures to both the SVG, left internal thoracic artery and native coronaryarteries were made, four of which during 2017 . In NovePostoperatively, there was a need for extended wound care because of delayed legwound healing related to the patient’s comorbidities. Diuretics and antibiotics wereused. In later postoperative controls, the wound was completely healed and thepatient had no complaints.After a three-year follow-up, the patient was completely asymptomatic. He kept activeby using a cycling machine daily, equivalent to 6,000 to 10,000 steps, without anyangina pectoris. He described a greatly improved quality of life and was very happywith the surgical outcome. After approval from the ethics committee (2020-02131) andinformed consent was obtained from the patient, a follow-up CT coronary angiographywas performed, showing that all vein grafts were patent, which corroborated therelief of angina pectoris and well-being of the patient (central picture andthree-year follow-up CT coronary angiography  in suppl. The use of the internal thoracic artery or other arterialgrafts are recommended, if applicable, during the redo procedure. In this case, apatient suffering from multiple comorbidities and use of the left internal thoracicartery during the primary CABG surgery, we did not consider the use of otherarterial grafts. The LAD was diffusely diseased and subject to several PCI-stents,which altogether required a longer graft to reach the LAD distally, thus, the use ofthe right internal thoracic artery was precluded. Furthermore, the risk ofmediastinitis in using the right internal thoracic artery was regarded as a greaterrisk than possible wound issues from the lower leg. Radial grafts were not an optionboth due to above-described coronary anatomy and also possible future need for ahemodialysis access. Thus, the no-touch saphenous vein graft was considered the bestoption,3,4.Current guidelines suggest redo CABG in cases of extensive and/or occluded grafts andin those with diffuse native vessel disease, based on studies from the AWESOMErandomized controlled studies and registryWe described a case of successful redo CABG using no-touch SVGs after recurrentunstable angina pectoris repeatedly and unsuccessfully treated with PCI. This caseillustrates that reoperation with good quality conduits can be the solution forcomplicated cases and it is in agreement with current recommendations.Clearly such cases require close communication and cooperation between cardiologistsand surgeons to avoid delays and unnecessary patient suffering in deciding the besttreatment modality. In this case, it is even more important since the patient wassuffering from chronic renal failure. Hence, excessive use of contrast agents shouldbe avoided. This patient received a total of 470 ml of contrast agent during PCItreatments in 2017, as well as excessive doses of radiation during angiographicassessments in the same year.


The primary aim of this systematic review is to provide perioperativestrategies to help restore or preserve cardiovascular services under threatfrom financial and personnel constraints imposed by the coronavirus disease2019 (COVID-19) pandemic.The Medical Literature Analysis and Retrieval System Online, Excerpta MedicadataBASE, Cochrane Central Register of Controlled Trials/CCTR, and GoogleScholar were systematically searched using the search terms “(cardiac ORcardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus ORSARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)”.Additionally, the webpages of relevant medical societies, including theWorld Federation Society of Anesthesiologists, the Cardiothoracic SurgeryNetwork, and the Society of Thoracic Surgeons, were screened for relevantinformation.Whereas cardiac surgery and cardiology practices were reduced by 50-75%during the pandemic, mortality of patients with COVID-19 increasedsignificantly. Healthcare workers are among those at high risk of infectionwith COVID-19.Hospitals must provide maximum protective equipment and training on how touse it to healthcare workers for their mutual protection. Triage managementof patients — which accounts for patient’s clinical status and risk-factorprofile relatable to which services are available during the COVID-19pandemic — is recommended. A strict reorganization of the hospital resourcesincluding preoperative, intraoperative, and postoperative detailedprotective measures is necessary to reduce probability of vectorcontamination, to protect patients and the cardiovascular teams, and topermit safe resumption of cardiological and cardiac surgical activity. The coronavirus disease 2019 (COVID-19) pandemic has made a global imprint that hasleft almost no one untouched. As of August 2021, over 215 million people areconfirmed to have been infected with COVID-19, with more than 4.6 million deaths,resulting in national and regional lockdowns and other emergency contingencymeasures across the globe. It is probable that this understates the true level inview of relative isolation in many communities. In tertiary care centers around theworld, since March 2020, many elective surgical procedures have been postponed orcancelled in large numbers, which leads to a backlog of nearly 30 million proceduresin just 12 weeks. In low- and middle-income countries (LMICs), where surgical caredelivery is already constrained by reduced availability of workforce,infrastructural capacity, geographical distance, and financial barriers, theCOVID-19 pandemic may have even larger consequences.Cardiac teams attempting to perform surgeries are now facing an unprecedentedchallenge from COVID-19 infection’s effects on the cardiovascular system. Among thewide variety of threats to health, cardiovascular disease (CVD) is now the leadingcause of death in the world and is responsible for nearly one-third of all globaldeaths. Since the year 2000, an increase in an individual’s lifespan has becomeevident, but one-third of CVD deaths have occurred in those aged between 30 and 70years — the most economically productive section of a country’s community. In somelocations, age-standardized CVD mortality rates showed a nearly six-fold higherlevel in 2019. In the African continent, CVD has become the leading cause of deathfor the first time in the history of the global disease estimates.. Somemajor hospitals are now threatened with closure. The immense shortage of evenrudimentary equipment for viral and general testing and clinical management, even atbaseline levels, that was applied prior to the pandemic now severely limit theability of cardiovascular teams to try to follow “gold standard” practices.Diversion of precious resources and funds from their programs is already takingplace. For many, livelihoods have been upended and elective procedures suspendedindefinitely; some are experiencing a reduction in pay to keep support staff andpractices afloat while others are now receiving no revenue at all.Six billion people in LMICs lack timely or ready access to safe and affordablecardiac surgical care when needed; it has a low priority on the global public healthand global surgery agendaWe conducted a systematic search of the Medical Literature Analysis and RetrievalSystem Online (or MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane CentralRegister of Controlled Trials (or CENTRAL/CCTR), and Google Scholar using thecombination of medical subject headings (or MeSH) and keywords “(cardiac ORcardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus ORSARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)”. Additionally,the webpages of the following medical societies were screened for relevantinformation: The World Federation Society of Anesthesiologists, theCardiothoracic Surgery Network, the Society of Thoracic Surgeons COVID-19,Centers for Disease Control and Prevention (CDC), American Society ofAnesthesiologists, Society of Critical Care Medicine, European Society ofCardiology (ESC), American College of Cardiology, and American Heart Association(AHA).Only articles written in English that reported relevant aspects of perioperativemanagement of patients with COVID-19 were included. Two reviewers (KP and AM)conducted the search independently and screened all article types foreligibility using their titles and abstracts. Duplicate and irrelevant articleswere excluded. Articles that did not address the primary objective and thosethat were correspondences and editorials were also excluded.COVID-19 is particularly important for cardiac and intensive care teams inLMICs:.Clinical infection with COVID-19 is associated with a higher morbidityand mortality in patients undergoing surgery , surgery may becomeimpossible to consider. The CVD burden is worsening and is continuing itsdecades-long rise for almost all low-income countries, doubling from 271 millionto 523 million.Lockdowns, furloughs, dismissals, and reallocation of essential staff areresulting in reduced services in many sectors; millions of people worldwide havelost their jobs. In some cases, these measures have taken away the single sourceof income of individuals and their entire families. Government cutbacks inbudget allocation per capita in LMICs have resulted in very limited financialsupport for tertiary care hospitals at this time of crisis. The lower surgicalvolume centers may inevitably suffer increased procedural costs due to lowerturnover and increasing overhead costs. The reduction in visits by internationalvisiting teams has reduced the number of philanthropic (subsidized) cases.Reports of patients dying on the waiting list are increasing; families arefacing a worsening financial situation. Where patients have to pay for part oftheir in-hospital care  and intensivecare unit (ICU) beds has been carried out to handle rapid growth in complicatedCOVID-19 cases. Previously contracted supply sources and surgical donations havebeen curtailed by border closures and travel restrictions, reducing theavailability of equipment and consumables. An elevated infection risk for healthworkers, especially those involved with invasive care, has become significantwith COVID-19 and may shift health workers from disease curers to vectors.In some instances, the loss of the lead cardiac surgeon and other essential teammembers in LMICs has forced closure. The unique pathophysiological impact ofCOVID-19 has led to worse outcomes among COVID-19-positive patients, both forthose infected before and after their operations. Reports are highlightingrespiratory and coagulopathic complication rates after cardiac surgery as aresult of COVID-19 infection, and some of these have produced a fatal outcome.There is still limited knowledge of the exact outcomes for patients undergoingdifferent cardiac surgical procedures and how specific risk factors may affectoutcomes.,10.Many of these advisorystatements are applicable in LIMCs.Although our understanding of many features of COVID-19 are changing weekly,several medical societies have made recommendations for those in advancedcenters.. Clinical management of allchronic cardiac conditions is changing substantially. ESC has issued aguidance document on how to prioritize management in patients with cardiacconditions.Patients with acute coronary syndrome (ACS), left main percutaneous coronaryintervention, pacing battery replacement, and valvular heart diseases thatare hemodynamically unstable should be considered emergent and should not bepostponed.Several authoritative bodies have offered guidelines and recommendations onhow to conserve resources and triage patients who need more urgentcareAs hospitals become increasingly populated with either suspected or confirmedCOVID-19 patients, separation of cardiac patients is needed with no staffcrossover, to minimize risk of nosocomial infection. As a short-termmeasure, reducing the number of cardiac surgical procedures will help thoseneeding ICU care for other reasons: vital equipment resources, ICU beds,ventilators, pharmaceuticals, personal protective equipment (PPE), andrepurposing staff with advanced skills will be more available. A negativeconsequence is the risk of losing essential staff. Cardiac surgery requiresa dedicated team of uniquely skilled individuals . Utilizing these individuals for non-essential operations orplacing them elsewhere may increase their chances of COVID-19 exposure, andit will reduce their availability for future more urgent cardiac proceduresthat do arise.,7,11. In addition to Tier 1 to3 for elective interventions, the cardiac surgery acuity scale includes:A cardiac surgery acuity scale builds upon the widely accepted ACS ElectiveSurgery Acuity Scale by accounting for inpatients that require urgent oremergent treatment. It is worth implementingTier 4a: urgent surgery required to permit safe hospitaldischarge.Tier 4b: urgent surgery required within 24 to 48 hours to preventclinical deterioration.Tier 5: emergent surgery required to prevent immediate death..A scoring system for MeNTS procedures can facilitate decision making andtriage in the setting of COVID-19, as recommended by Prachand etal.They describe a scoring system that integrates factors, such as resourcelimitations and COVID-19 transmission risk, to providers and patients toguide triage for MeNTS procedures and weigh individual patient risks.with and without symptoms. Both effects may beevident in some patients who have pre-existing cardiac disease. If available,myocarditis can be identified by cardiac magnetic resonance imaging(MRI).Elevated troponin levels or electrocardiogram (ECG) abnormalities were foundin 7% to 28% of hospitalized patients with COVID-19 and were associated withpoor outcomes.While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mostcommonly affects the respiratory system, some patients experiencecardiovascular effects .The European Association of Percutaneous Cardiovascular Interventions (EAPCI)position is recommended here — they issued a position statement on invasivemanagement in patients with ACS during the COVID-19 pandemicThe EAPCI recommends that in cases of mild troponin elevation , particularly in older patients with pre-existingcardiac conditions, a work-up for type-1 myocardial infarction is notindicated, unless strongly indicated by clinical presentation and ECGfindings. for the treatment of viral myocarditisare applicable in most settings, they include the use of standard heartfailure therapies and supportive measures. An position statement of theEuropean Society of Cardiology Working Group on Myocardial and PericardialDiseases remains helpful in clinical management.Current guidelines proposed by Caforio et al.routine use of such steroids in these patients, whichmay also cause harm.Selective use of prednisolone has shown benefit in some case reports,however, there is insufficient evidence to support theCOVID-19 infection has now clear association with abnormalities in bloodclotting. Anticoagulation treatments to stop clotting could be beneficialthough evidence to date is not based on wide analysis nor beyondobservational studies.We recommend follow-up review in patients who exhibit structural andfunctional abnormalities, they should have an echocardiogram 1-3 monthsafter discharge and then monitored for a minimum of six months, with heartfailure therapy tailored to damage observed and recovery delays. Monitoredexercise testing may also be required and determined according to futureemployment type.Rheumatic heart disease (RHD) regularly affects the poorest countries andtheir communities, posing potential complications from COVID-19 because oftheir links with cardiac health and functioning. Around 33.4 million peopleworldwide have been estimated to be suffering from rheumatic fever andensuing RHD. At present, data is not fully available about the vulnerabilityof patients with RHD and the impact of COVID-19 infection. RHD patients mayhave left chamber dysfunction of the heart or elevated pulmonary pressurewhich may predispose them to complications of COVID-19..Chagas disease, caused by a tropical parasite, affects around 6 millionpeople. It may affect the heart in some patients. Those with Chagas diseaseshould follow the same recommendations as the general populationSocioeconomically deprived patients require clinicians to be especiallysensitive to the issues they face. Low socioeconomic status stands alone asan important risk factor for total mortality independent of any other riskfactors. Lockdown, loss of job, spousal tensions and/or abuse, threat ofdying on waiting list, threat of hospital closure, poor access to food,unavailability of essential medications, evolving mental health issues, fearof disease that may be spread within a hospital, and fears surrounding theirperception of operative outcome are common. Viral infections are now alsoviewed as independent risk factors for cardiovascular events such as heartattack.An essential part of clinical history-taking and examination by thecardiologist is the harmonious and disarming relationship that should bebuilt within the first five minutes to reduce the reasonable anxiety of thepatient.Show one’s face on first greeting the patient, using appropriate distance orscreen protection, should help. Hiding behind the mask and denying anyphysical contact obstructs that vital interaction — especially in childrenor young adults. During interview in the clinic, a workable compromise is towear an N-95 mask and clear face-shield, then briefly pull the mask down toshow one’s face before continuing the interview (and on completing it).To perform perioperative echocardiography with pre- and post-comparisons may help demonstratediffuse myocardial dyskinesia and pericarditis in COVID-19 suspectedcases.Complete COVID-19 testing close to the planned operative date (preferably< 48 hours) helps to lessen the risk that a patient becomes positivewhile waiting for a surgical procedure.It is recommended to avoid emergency surgical procedures during off-dutyhours, when possible, due to limited team staffing and the potential lack ofoptimal specialty-specific expertise.. Patients should be advised that undergoingsurgery with perioperative or recent SARS-CoV-2 infection appears to be atincreased risk of postoperative venous thromboembolism compared withpatients with no history of SARS-CoV-2 infection.On the day of interview, the patient’s pulmonary function should be assessedbefore surgery to assist with decisions about planning later separation fromthe ventilator postoperatively. Over 12% of COVID-19 patients may notdevelop a fever at first evaluation, nor at admission, nor be symptomaticuntil several days postoperativelyonly family member to accompany them to the hospitaland be available throughout the perioperative period.If possible, a family relative should be selected by patients to be theFor both pediatric and adult patients, timing of and reducing the number ofclinic visits helps avoid unnecessary exposure to other patients and theassociated stress factors that may be present. A single evaluation performedby the cardiologist and respiratory therapist (RT) preoperatively at 12-14days before surgery can help support a pre-admission assessment that yieldsmost information. This should include standard COVID-19 testing,preoperative blood panel, temperature, chest X-ray, and respiratory andecho-cardiological assessments. Pre- and post-comparisons followingoperation may help demonstrate diffuse myocardial dyskinesia andpericarditis in COVID-19 suspected cases. The role of the RT is vital — inone report, patients with COVID-19 infection on ventilators developed morebarotrauma than patients who required intubation for other reasons.It is vital to ensure that essential PPE items are well stocked beforesurgical planning takes place.locally constructedpolicies for staff, patients, and their relatives to follow and developlocally relevant teaching protocols for perioperative COVID-19 preventativemeasures, including nosocomial causes.The institution must have consistent   which may be accompanied by othersymptoms .Enquiring about perceptions of measured distance walking in older adults mayalso help give information on oxygen saturation changes .On admission, the RT should manage the preoperative and postoperative careduring the ICU stay. This strategy may not capture all those alreadyinfected with COVID-19, those who were exposed just prior to admission, orthose who may later infect others, but it may reduce the number of peopleexposed.are available and thepatients test positive for COVID-19, they are best moved to an area separatefrom other perioperative patients.If no test kits are available, it is safest to assume that the patient isinfected and, if at all possible, continue separating the patient from otherperioperative patients. If tests kits Nurses caring for patients diagnosed with COVID-19 or suspected to beinfected should not take care of non-infected patients..In choosing who to operate on after first ensuring availability of a largestock of essential disposables and determining urgency of the procedure, werecommend prioritization as suggested by Stephens et al.In prioritizing patients, consideration to comorbidities and likely timerequiring ventilatory support is important.Telemedicine techniques should be used where possible. The development oftelemedicine adjuncts via Zoom, Facetime, Skype, WebEx, Doximity, and othersimilar platforms are a welcome technological advance that make it possiblefor doctors and healthcare personnel to be more accessible to patients andtheir questions, and yet remain safe. For resource-poor locations strugglingto develop their programs, however, internet access may not be easilyavailable or reliable and may not have the bandwidth to support theseplatforms. Many patients in poor and remote locations may not have access toa computer or cellphone ..COVID-19 preventative measures are sometimes difficult to teach remotely; theavailability of hand-sanitizer may be limited, and hygienic bathroomfacilities may be lacking. In resource-poor hospitals, lavatories may lackdaily cleaning routines, antiseptic soap, and paper; their design featuresmay encourage fomite transmission. The situation is usually worse in towns,bus stations, and other typically crowded areas so contamination levels caneasily rise. People vary in their perception of how a virus can afflict anindividual. The precautions of wearing masks and frequent hand washing maynot be strictly observed nor presented as a required routine, and facilitiesare, in any case, less available there. International recommendationsdeveloped by the World Health Organization and followed in many individualcenters of excellence should be implemented when possible to prevent anincrease in infection among patients and colleaguesThe priority is for doctors and other healthcare leaders to model theirpractice by example, and to use media and press releases to promotethem.Modern designs for laminar flow delivery which include regularlyinspected and changed filters may not be available in LIMCs. Insubtropical and tropical regions, a fan perched in the corner of theOR or ICU is sometimes used in an effort to decrease the roomtemperature to make working conditions more tolerable. It will,however, disperse contaminated droplets throughout a room.. Purifiers that are marketedlocally should exhibit a clean air delivery rate (CADR) to whichsome countries require certification. It defines how quickly apurifier can rid the air of specific types of particles, includingdust and smoke — which may be roughly in the same size range asaerosols bearing SARS-CoV-2. A HEPA purifier with a CADR score of300 would clear 99% of particles from a room measuring 10 by 10 by10 feet.If possible, modifying the OR suite to allow foot or elbow-operatedsliding doors guarding entry into the OR may reduce the fan effectof ordinary door opening. Currents of air can increase if outsidecorridor windows and doors are left open. Air purifiers or cleanerswith a high-efficiency particulate air (HEPA) filter are necessaryto remove viruses: they are more than 99.7% efficient. In a study ofa hospital room occupied by two COVID-19 patients at the Universityof Florida Health, HEPA filters were attached to air samplingdevices. Although SARS-CoV-2 ribonucleic acid was found in many ofthe patients’ exhaled air samples, it was absent in emergent airthat had passed through the HEPA filters — suggesting that thesedevices do block the pathogen effectively. They may stay suspended in the air forhours or fall onto equipment, depending on the airflow patterns ortype of ventilation available. In laboratory-createdrespirable-sized aerosols, Fears et al. reported that the virus couldretain infectivity for up to 16 hours. The impact of COVID-19transmission is teaching us that our tendency to wander in and outof the OR and into the ICU — or outpatient area  — is adangerous habit that should not continue.Relevance: The vapor of the exhaled breath, sneezes, and coughs canproject an aerosol missile of droplets up to 10 feet; existing aircirculation, room temperature, and humidity level can extend thatdistance even further. The locally moist and warm atmosphere withinthe gas cloud allows virus-containing droplets to evade evaporationfor longer than with isolated droplets. Under these conditions, thelifetime of a droplet can extend by a factor of up to 1000, from afraction of a second to minutesfrom any cause, and whether or not PPEs areavailable to them on arrival.Each team member should check if the mask they chose to use isadequate, whether or not they should come into work if symptomaticGowning up: The close physical space within which the surgical teamoperate on the heart patient may require a change in practice tofollow the example of gowns and hoods worn by orthopedic teamsduring joint replacement. The exception to that is the requirementof loupe magnification glasses and headlights which cannot be easilyused within a plastic visor.Fresh gowning upon entering the ICU is important and changing out ofscrubs upon leaving the ICU or the OR may become the norm, eventhough it is inconvenient and requires extra stocks of PPE.Respiratory treatments: In perform aerosol-generating procedures(AGPs) in confirmed or suspected COVID-19 patients, practiceenhanced droplet/contact precautions, including an N95 mask, eyeprotection, gown and gloves, or a powered air-purifying respirator.AGPs include intubation, extubation, bag mask ventilation,noninvasive ventilation (continuous positive airway pressure andbilevel positive airway pressure), airway suctioning, nebulizertherapies, bronchoscopy, chest tube insertion, thoracotomies, andpleural procedures.Transfers: Patients are best transferred directly to the OR, withoutstopping in the preoperative or post anesthesia care unit areas, tominimize exposure to other patients, staff, and otherenvironments.“COVID-19 precautions” signs should be posted on all doors of the ORsuite to inform staff of potential risks and minimize exposure.Negative pressure ventilation at more than 2.5 PA, at 12 or more airchanges, can improve OR traffic movements and increase safety ofpatients and staff.In view of the possibility of false-negative COVID-19 testing(10%-30%), the American Society of Anesthesiologists recommends thatall anesthesia professionals use PPE appropriate for AGPs for allpatients during all diagnostic, therapeutic, and surgical procedureswhen working near the airway.If N95 masks are to be reused, ultraviolet germicidal irradiation,vaporous hydrogen peroxide, or moist heat by autoclaving may beused, if available.One staff member should adopt the role of being thedonning-and-doffing observer because most nosocomial spread ofCOVID-19 occurs during this critical period.Limit entry/exit to a single OR entrance, keeping all OR doors closedas much as possible, and limiting staff entry/reentry to keep ORpressures and air exchanges regulated.Before AGPs are performed, OR personnel should ensure that no morethan the minimal number of staff required to safely achieve theprocedure are allowed to be in the room.Staff reliefs for breaks are essential to maintain focus and morale:these should be factored into the morning’s arrangements andorganized to preserve PPE and minimize re-entries to the OR..Surgical approach and techniques may have to be reevaluated tooptimize patient outcomes while minimizing exposure risk toproviders. Use of laparoscopic or video-assisted thoracoscopicprocedures may have to be deferred due to risk of aerosolizationfrom CO2 insufflation systemsA clear barrier screen is vital to limit aerosol transmission acrossthe head of the table; limiting those who are allowed to touchequipment, syringes, medications, and crystalloid/bloodproducts.Rapid sequence induction is preferable for airway management of aCOVID-19+ or highly suspected patient. Induction can be performedaccording to usual airway management for non-COVID-19 patents.Limit the number of staff in the OR to the minimum needed to safelyintubate (one anesthesiologist plus one or two assistants).Video-guided laryngoscopy may be chosen over direct visualization todecrease the risk of droplet transmission.Preoxygenate with 100% inspired oxygen and avoid bag-mask ventilationunless necessary. When resources permit it, patients are bestrecovered in a negative pressure isolation room (in thepost-anesthesia care unit or ICU). Early recovery in the OR beforetransfer to a single patient room is favorable.After the patient has left the OR, the OR should be closed for anappropriate standoff period to achieve > 99.9% aerosol clearance.The amount of time that aerosols stay suspended in the air willdepend on a number of factors, including the size of the room, thenumber of air changes per hour, how long the patient was in theroom, whether the patient was coughing or sneezing, and whether ornot an AGP was performed. General guidance on clearance rates underdiffering ventilation conditions is available from the CDC, UnitedStates of America.After the standoff period, the OR suite must be cleaned using routineprocedures with approved hospital disinfectant on all surfaces,including drip stands and monitors.COVID-19 repeat testing is only required in postoperative patientswhen symptoms or signs of COVID-19 develop. Rapid polymerase chainreaction (or PCR) based COVID-19 testing is preferred whenavailable..In the event of cardiac arrest or other medical emergency, allpatients should continue to be treated as suspected or confirmedCOVID-19 cases when performing cardiopulmonary resuscitation. Thisrequires strict adherence to enhanced contact and dropletprecautions. No patient interaction should occur before full PPE isdonned. This paradigm shift for physicians accustomed to “jumpinginto lifesaving patient interactions with little regard toinfectious risk” will be an uncomfortable transition. As best as itis possible within locations of LMICs, is helpful to follow theguidelines presented by many international societies like theInternational Liaison Committee on Resuscitation (or ILCOR), AHA,and Resuscitation Council UK. They offer regular interim updates andmodified guidelines for resuscitation during COVID-19pandemicin vitro virucides against similarcoronaviruses (SARS-CoV and Middle East respiratorysyndrome-coronavirus) . They may have value when used as a preoperative mouthrinse, before surgery prior to transfer to the OR. Followinginduction, mouth or nasal painting with a sponge may also help toreduce risk of contamination to anesthesia personnel.Povidone iodine or popular mouthwashes and nasal rinse products areeffective Following reversal of heparinization, introduction of aspirin orfractionated heparin (as is used for hip surgery) may reduce theincidence of future thromboembolism..Nitric oxide may also help to reduce respiratory tract infection byinactivating viruses and inhibiting their replication in epithelialcells, but it is expensive and, in some locations, may be difficultto obtainStrictest adherence to bathroom cleanliness, minimizing sharing, isadvised.Limiting those allowed to enter the hospital (one patient and onerelative) will help reduce the traffic of people in vital careareas.If at risk patients are discharged early, the use oftelecommunications for following up with them is recommended.Isolation with one supporting relative for 14 days following surgerymay be the best way to limit complications and contamination byothers in the household.The risk of neurological damage as a result of cardiac surgery is aconstant source of concern to cardiac surgeons in their endeavor toprotect the cerebral and spinal circulation during the operation. Italso has a potential for medico-legal intrusion. COVID-19 infectionmay complicate the clinical scenarios that are difficult todistinguish between COVID-19 and pre-existing cardiac issues nowunmasked or altered despite a perfectly executed operation..While the pulmonary complications have received considerableattention, it is the neurological manifestations that are disabling,persistent, and common in patients infected with SARS-CoV-2. Theentire neuro-axis can be involved resulting in a wide variety ofmanifestations. SARS-CoV-2 infection may be associated withencephalopathy and encephalomyelitis, ischemic stroke, intracerebralhemorrhage, anosmia, and neuromuscular diseases. The neurologicalstatus of the patient should therefore be carefully reviewed beforeand after surgery using identical evaluative clinical tools.Neurological screening checks need to be thorough and similar in allpatients; routine interventional procedures and cardiac surgery mayproduce particle or air embolism despite protective measures. Recentstudies with preoperative and postoperative MRI suggest that a largepercentage of patients do suffer silent cerebral infarcts eventhough they appear to have had an uneventful procedurePreoperative checks: Perform clearly documented and detailed enquiryinto any neurological symptoms, communication difficulties in verbalexchange, physical signs, and writing skills. Completion of consentforms and other routine documentation can help identify suchdeterioration. Repeat simple questions about date of birth, addressinformation, and who is at home  to determine limits oncognitive ability or impairment. This should include informationabout right or left-handedness, gait, and/or need for walkingaids.Intraoperative check: A mutual check with anesthesia colleagues toensure central line taps/spigots are luer-locked and can permit easyblood draw back before draping. Follow carefully planned myocardialprotection, then ensure no air entrapment occurs that might migrateto the coronary arteries or cerebrally on completing the cardiacprocedure.-32. Bloodtypes A or AB in COVID-19 patients were associated with increased risk forneeding mechanical ventilation, continuous renal replacement therapy, andprolonged ICU admission vs. patients with blood type O orB. Inflammatory cytokines levels did not, however, differ between groups insome studies. The virus which causes yellow fever (transmitted by fleas) is40-50 nm in width and is transmissible through filtered human serum. TheCOVID-19 virus size ranges from 50-200 nm.Blood groups are increasingly recognized to influence susceptibility tocertain viruses, among them SARS-CoV-1 and norovirus; individuals with A, B,and AB blood types may be at “increased risk for thrombosis andcardiovascular diseases”, which are important comorbidities among patientshospitalized with COVID-19This raises the question as to the value of using blood products obtained bydonation due to uncertain deleterious consequences. In view of the risk ofviral transfer through standard filters, surgeons will have to give moreattention to hemostasis, meticulous conservation of blood, and the principlethat avoidance of blood and plasma use is desirable. Jehovah’s Witnesspatients have taught us to be more careful about hemostasis and thatavoidance of donor blood can still usually lead to a safe outcome. Whetheror not following this practice produces more certain and favorable outcomesin patients in which COVID-19 exposure is evident is currently uncertain.Leukoreduction of cellular blood products (particularly pre-storageleukoreduction done shortly after blood collection) is beneficial inprevention of multiple harmful effects of blood transfusion.This is a new pandemic. Adjustments to patient consent forms will be requiredfor procedures and surgery so that healthcare personnel’s risk of liabilityis limited. CardioStart International has one that is legally approved ofits international assistance to cardiac programs.Healthcare workers who follow government guidelines in providing care in goodfaith during the public health emergency and in a reasonable time period maystill not be adequately legally protected and the risk of ill-health amonghealthcare personnel is substantial.Few countries in resource-deprived settings have fully established trainingprograms. The consequence of the COVID-19 pandemic for primary careproviders in these settings is the loss of training and mentorship formembers of these healthcare teams. The six leading modifiable CVD riskfactors include high systolic blood pressure, diet, high low-densitylipoprotein cholesterol, air pollution, high body mass index, and tobaccosmoking. These are vitally important to identify, track, and counselpatients about, especially in communities living remotely from cities andthe burden placed on healthcare workers throughout the community networkwill be much greater.i.e., cardiac surgeons, cardiologists, intensivistsand anesthesiologists, nurses, perfusionists, and technicians in the OR andICU) to retain a consistent and high standard of care. In some centers,colleagues will have to make do in a more restricted environment and will bereluctant to take on complex cases or teach a procedure. The potential formedico-legal risks will also likely rise which would lead to a reluctance toallow junior doctors to do cases under supervision.It is clear that established pediatric and/or adult heart programs will beimperiled: they require a full complement of suitably trained specialists(Every year, millions of people are dying and millions more are becoming disabled dueto treatable cardiac surgical diseases. Surgical capacity is unevenly distributedaround the world and disproportionally affects populations in LMICs. COVID-19increases barriers for access to cardiac surgical care, and high-level action isurgently needed to not only expand cardiac services around the world but also toensure health systems are strengthened so that cardiac patients can be effectivelymanaged during and after the pandemic.