6. Is here an increased patient risk for cardiac surgery/cardiac intervention/heart transplantation during COVID-19 pandemic?

6. Is here an increased patient risk for cardiac surgery/cardiac intervention/heart transplantation during COVID-19 pandemic?

The incidence of Covid-19 remains low in children. Numbers are quoted to be between 2% and 12% (depending on testing), with a generally milder course, but with variable symptoms that may mask the viral infection and cause delay in making the diagnosis.

Despite common sense judgement that preexisting cardiac diseases should impose children with CHD to a higher risk this has only rarely been demonstrated to date (31).

The following strategies should minimize risk of cardiac surgery during Covid-19 pandemic:

• Prioritization of cardiac surgery, leaving surgical activity to urgent and emergency procedures.
• Avoid delay of urgent cardiac surgery.
• CHD-patients planned for cardiac surgery if not an emergency should have tested negative for SARS-Cov-2- reverse transcription polymerase chain reaction.
• Test- and symptom-based precautions to avoid transmission: separation of positive tested Covid-19 patients from non- Covid-19 patients irrespective of symptoms. Staff working in rotations.
• Full personal protective equipment should be mandatory for staff who is performing cardiac intervention for Covid – 19 positive patients.
• In CHD-patients positive for SARS-CoV-2 (test or symptoms) surgery should be delayed until test is negative or symptoms relieved (usually 14 days) if clinically justifiable.
• Provide extensive logistics including anaesthetic and and intensive care considerations to protect patients and medical staff.
• Continue transmission precautions at least 14 days after discharge from the hospital.

Paediatric heart catheterization and intervention in Covid-19 patients has been required in exceptional circumstances. Elective cases have in general been postponed from the beginning of the pandemic. Meanwhile, as the numbers of affected children remain low, it seems reasonable to activate the programs while continuing to use personal protective equipment and following institutional flow algorithms for Covid-19 patients, including switch to negative pressure environment in the catheter laboratory if possible. A comprehensive guidance paper addresses most aspects of decision making and resource allocation (32). The subgroup of adults with CHD are likely to have the highest risk within patients with CHD (5) as, at least in complex cases, premature aging of the heart may be present together with limited cardiac reserve, thus lacking the advantage of children that are in general less susceptible to symptomatic SARS-CoV-2 infections.

Heart transplantation / Immunosuppression: While immunosuppression in general enhances the risk for viral infections and increased severity, as has been described for younger children with influenza, this does not seem to be the case in SARS-CoV-2 infections. Data from solid organ transplantation do not show that immunosuppression during Covid-19 pandemic leads to a less favorable outcome. Immunocompromised children, for example those treated for cancer, only rarely needed modifications of their treatment. Accepting that not all patients are tested for Covid-19 at least symptomatic worsening has not been observed (33). Nevertheless, transmission precautions are of paramount importance and should be strictly followed until further knowledge of SARS-CoV-2 impact on the immune system is available (34).