Journal Pre-proof

The fate of patients with acute aortic syndrome during Covid-19 Pandemic: a UK
multicentre study

Ana Lopez-Marco, PhD, Barbara Rosser, MD, Amer Harky, MD, Danilo Verdichizzo,
MD, Iain McPherson, MD, Emma Hope, RN, Syed Qadri, MD, Aung Oo, MD, on
behalf of the UK AS Research Group
PII: S2666-2736(20)30149-2
DOI: https://doi.org/10.1016/j.xjon.2020.11.008
Reference: XJON 104

To appear in: JTCVS Open

Received Date: 8 November 2020

Accepted Date: 17 November 2020

Please cite this article as: Lopez-Marco A, Rosser B, Harky A, Verdichizzo D, McPherson I, Hope E,
Qadri S, Oo A, on behalf of the UK AS Research Group, The fate of patients with acute aortic syndrome
during Covid-19 Pandemic: a UK multicentre study, JTCVS Open (2020), doi: https://doi.org/10.1016/
j.xjon.2020.11.008.

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Copyright © 2020 The Authors. Published by Elsevier Inc. on behalf of The American Association for
Thoracic Surgery
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 1 TITLE PAGE

3 TITLE

4 The fate of patients with acute aortic syndrome during Covid-19 Pandemic: a UK multicentre

5 study

7 AUTHORS

8 Ana Lopez-Marco1 PhD, Barbara Rosser2 MD, Amer Harky3 MD, Danilo Verdichizzo4 MD,

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9 Iain McPherson5 MD, Emma Hope6 RN, Syed Qadri7 MD, Aung Oo1 MD on behalf of the

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10 UK AS Research Group.

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UK AS Research Group: Aung Oo, Geoffrey Tsang, Alex Cale, Jorge Mascaro, Mark Field,
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12 Manoj Kuduvalli, Giovanni Mariscalco, Jon Anderson, Sunil Bhudia, Ulrich Rosendahl,
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13 Jonathan Hyde, George Krasopoulos, Stefano Forlani, Karen Booth, Uday Dandekar, Kelvin
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14 Lim, Reuben Jeganathan, Nidal Bittar, Mazyar Kanani, Hussein El-Shafei, L

15 Balacumaraswani.
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16
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17 INSTITUTIONS:

18 1. Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London

19 2. Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust,

20 London

21 3. Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital,

22 Liverpool

23 4. Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford

24 5. Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle

25 6. Department of Cardiothoracic Surgery, Southampton University Hospital,

26 Southampton

27 7. Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool

28

29

30 CORRESPONDING AUTHOR:

31 Ana Lopez-Marco

32 St Bartholomew’s Hospital

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33 West Smithfield

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34 London EC1A 7BE

35 United Kingdom
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36 Telephone:
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37 E-mail: ana.lopez-marco@nhs.net
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39 No conflict of interest to declare. No funding received.

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40 Individual patient consent was waived by the local Ethical Research Board due the
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41 anonymised nature of the data.

42

43 WORD COUNT: 2845

44

45 ACKNOWLEDGEDMENTS:

46 Yama Haqzad (Hull), Luke Holland and Joanne Jessup (Brighton), Yusuf Abdullahi

47 (Hammersmith), Vamsidar Dronovalli (Birmingham), Andrew Brazier (Coventry), George

48 Gradinariu (Aberdeen), Saif Mohamed and Deepthy Blesson (Stoke), Marius Roman

49 (Leicester), Anne Gregg and Ronan Kelly (Belfast), Tracey Smiles (Middlesbrough),
50 Amanda Finch (Blackpool), Martin Yates and Julie Sanders (St Bartholomew’s Hospital,

51 London)

52

53 GLOSSARY OF ABBREVIATIONS

54 AAS: acute aortic syndrome

55 A&E: Accident and Emergency

56 CT: Computed Tomography

57 FFP: Filtering Face Piece

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58 LDH: Lactate Dehydrogenase

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59 NHS: National Health Service

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PCR-RNA: Polymerase Chain Reaction analysis of Ribonucleic Acid
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61 PPE: Personal Protection Equipment
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62 SCTS: Society for Cardiothoracic Surgery in Great Britain and Ireland

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63 TEVAR: thoracic endovascular aortic repair

64 UK: United Kingdom

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65 UK AS: United Kingdom Aortic Surgery Group

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66

67 CENTRAL PICTURE LEGEND

68 COVID-19 and surgical AAS mortality in the UK. COVID scale = x100 AAS mortality.

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70 CENTRAL MESSAGE

71 The service provision for AAS has been maintained during the early months of the COVID-

72 19 pandemic in the UK with a very low rate of surgical turn down and COVID-19-related

73 complications.

74
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76

77 PERSPECTIVE STATEMENT

78 Although most patients were operated on an unknown COVID-19 status, due to the natural

79 history of AAS outweighing the risk of post-operative respiratory-related complications, only

80 a minority of patients developed COVID-19 disease and that did not influence outcomes.

81 With appropriate precautions, emergency surgery can be provided to patients with AAS with

82 good outcomes during COVID-19 Pandemic.

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85
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86 STRUCTURED ABSTRACT
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87
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88 OBJECTIVE

89 The COVID-19 Pandemic posed challenges to healthcare services across the world. There
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90 has been a significant restructuring of healthcare resources to protect services for patients
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91 with COVID-related illness and to maintain emergency and urgent medical and surgical

92 activity. This study assess access to emergency treatment, logistical challenges and outcomes

93 of patients with acute aortic syndrome during early months of COVID-19 Pandemic in the

94 United Kingdom.

95

96 METHODS

97 A multicentre study participated by 19 cardiac centres from 1st March to 20th May 2020. A

98 retrospective analysis of prospectively collected data obtained from individual centres’

99 national cardiac surgical database. Demographic details, choice of treatment, operative details
100 and outcomes were collected. COVID screening, timing of surgery and outcomes of COVID

101 positive and negative patients were also analysed.

102 RESULTS

103 88 patients presented with acute aortic syndrome to participating centres from 1st March to

104 20th May 2020. There were 79 aortic dissections (89.8%), 7 intramural haematomas (7.9%)

105 and 2 penetrating aortic ulcers (2.3%).

106 Seventy-nine patients (89.8%) underwent surgery. In-hospital mortality was 25.3% (n= 20).

107 Postoperative complications included: 13.9% postoperative stroke – 11.4% permanent and

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108 2.3% temporary, 16.5% rate of haemofiltration and 10.1% rate of tracheostomy. 9 patients

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109 were treated conservatively with mortality of 60%.

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7 patients were diagnosed with COVID and there was no associated mortality.
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112 CONCLUSION
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113 Despite of extensive restructuring of healthcare resources, access to emergency and urgent

114 treatment for acute aortic syndrome patients was maintained in the early months of COVID-
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115 19 Pandemic in the UK. Clinical outcomes were similar to pre-pandemic period.
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125

126

127 GRAPHICAL ABSTRACT

128

UK Multicentre study - 19 aortic centres

n = 88 with AAS
79 patients (90%) underwent surgery

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25% mortality – non-COVID related and similar to
pre-pandemic figures

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Despite COVID-19 screening results not awaited,
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only 7 patients diagnosed of COVID in the
postoperative period and not related-mortality
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Access to emergency treatment and outcomes for
AAS were maintained despite health care
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restructuring during the COVID-19 pandemic

129
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130 KEY WORDS

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131 Aorta; acute aortic syndromes; emergency surgery; COVID-19 pandemic

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132

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142

143 MAIN TEXT

144

145 INTRODUCTION

146 The COVID-19 pandemic affected all aspects of life of people across the globe to an

147 unprecedented level. It has posed relentless challenges to healthcare services of every

148 countries. Governments and healthcare systems were tasked with achieving a balance

149 between public healthcare in containing SARS-CoV-2 viral infection and maintaining acute

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150 medical services to reduce mortality secondary to acute cardiovascular emergency conditions.

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151 This has led to extensive reorganisation of healthcare services in every region which involved

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protection of critical care facilities for treatment of COVID-19 affected patients and deferring
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153 elective surgery. In parallel with this healthcare resource management, medical societies
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154 developed modified guidelines for patient selection and indications for emergency and urgent
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155 treatments. [1-4]

156 In United Kingdom (UK), like the rest of the world, all elective cardiac and aortovascular
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157 surgery were put on hold in order to protect patients access to emergency and urgent surgery.
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158 Patients with acute aortic syndrome, having a devastating natural history with incremental

159 hourly risk of mortality, require emergency surgery. [5]

160 In this study, we assess the incidence, access to emergency treatment, logistical issues as well

161 as clinical outcomes of patients presented with acute aortic syndrome (AAS) during the early

162 part of COVID-19 pandemic in UK.

163

164 METHODS

165 A multicentre service evaluation study was designed and 19 centres across UK were recruited

166 to assess the access for treatment, logistical limitations and clinical outcomes of patients with
167 thoracic aortic diseases during COVID-19 Pandemic. The study period commenced from 1st

168 March 2020 and patient recruitment is still ongoing at the time of data analysis for the initial

169 experience.

170 The 19 participating centres, grouped by regions are: London – St Bartholomew’s Hospital,

171 Royal Brompton and Harefield Hospitals and Hammersmith Hospital; Southeast - Royal

172 Sussex County Hospital (Brighton), University Hospital Southampton and John Radcliffe

173 Hospital (Oxford); West Midlands - Queen Elizabeth Hospital (Birmingham), University

174 Hospital Coventry and Royal Stoke University Hospital; East Midlands - Glenfield Hospital

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175 (Leicester); Northwest - Liverpool Heart and Chest Hospital and Blackpool Victoria

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176 Hospital; Yorkshire and Humberside - Sheffield Teaching Hospital and Castle Hill Hospital

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(Hull); Northeast - Freeman Hospital (Newcastle) and James Cook University Hospital
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178 (Middlesbrough), Scotland -Royal Infirmary of Edinburgh and Aberdeen Royal Infirmary,
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179 and Northern Ireland - Royal Victoria Hospital (Belfast).

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180 These centres represent 66% of the aortic units in the country, including the largest

181 specialised aortic centres and cover most of the geographical areas.
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182 The other 15 aortic units declined to participate in the study for different reasons including
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183 inability to provide emergency surgery cover during the COVID-19, insufficient resources to

184 collect the data and/or individual preferences.

185

186

187 In this sub-study, we evaluated the access to emergency and urgent treatment, logistical

188 limitations and clinical outcomes of patients presented with AAS to participating centres

189 from 1st March to 20th May 2020.

190
191 Retrospective analysis of prospectively collected data obtained from the National Cardiac

192 databases of the individual centres. Details about preoperative demographics and risk factors,

193 type of acute aortic syndrome, DeBakey classification, treatment of choice, operative details,

194 outcomes and postoperative complications were obtained from National Cardiac Databases of

195 the individual centres. A detailed analysis of the COVID-19 screening peri-operatively and

196 its effect on decision making and timing of the treatment were also analysed. The

197 anonymised patient data from individual centre were transferred securely to St

198 Bartholomew’s Hospital for data cleaning and analysis. Data analysis was performed with

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199 SPSS version 25.

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200 Ethical approval was obtained from each participating centre after acceptance of the study

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protocol at the recruiting centre (St Bartholomew’s Hospital). Individual patient consent was
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202 waived due the anonymised nature of the data.
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203
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204 Modification of guidelines for patient selection and management for patients with

205 aortovascular conditions during the COVID-19 Pandemic

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206
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207 A modified protocol for patient selection and treatment of aortovascular conditions during

208 COVID-19 Pandemic was developed on 25th March 2020, following a multidisciplinary team

209 consultation involving cardiac surgeons, vascular and endovascular surgeons, interventional

210 radiologists, cardiologists with interest in aortopathy, clinical geneticists, anaesthetists and

211 intensivists at St Bartholomew’s Hospital. It was developed after reviewing all existing

212 clinical guidelines from international clinical societies and, also taken into consideration of

213 the potential increased risk of treatment if patient were to be infected with SARS-CoV-2

214 perioperatively. [6] It was endorsed by the UK Aortic Surgery Group (UK AS) and the

215 Society for Cardiothoracic Surgery (SCTS).

216 The protocol defines the cohort of Aortovascular patients eligible for referral and treatment

217 during the COVID-19 Pandemic, triaged in several categories depending on the level of

218 urgency at time of referral/presentation. Patients with AAS and ruptured aneurysms of any

219 anatomical location were categorised as Emergency conditions and was agreed that should be

220 accepted and operated at the earliest opportunity, including out-of-hours, due to the increased

221 risk of mortality while waiting.[5] This modified protocol was widely adopted in all

222 participating centres.

223

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224 Preoperative COVID-19 screening

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225 On 26th March 2020, a preoperative screening protocol for SARS-CoV-2 virus was

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introduced at St Bartholomew’s Hospital after multidisciplinary review of available evidence
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227 and Public Health England guidance [7]. It included a combination of two negative
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228 nasopharyngeal swabs for polymerase chain reaction for ribonucleic acid (PCR-RNA)
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229 analysis, a non-contrast CT thorax to assess changes in the lung parenchyma suggestive of

230 COVID-19 disease and analysis of the Lactate Dehydrogenase (LDH) levels and Lymphocyte
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231 counts. This screening protocol was disseminated through the SCTS to the rest of UK and
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232 was adopted widely. [8, 9]

233 However, in cases of AAS patients requiring emergency surgery, although nasopharyngeal

234 swabs were taken on admission to cardiac surgical centres, the surgical teams proceeded

235 without waiting for results. This was due to the balanced decision as the incremental time-

236 delay related increased risk of mortality being more significant than the risk of increase

237 perioperative complications from COVID-19 infection. [8, 9]

238 Irrespective of the patients COVID-19 status, the surgical procedures and postoperative care

239 in ITU environments were performed using universal measures of personal protective

240 equipment (PPE) [10] and with a limited number of theatre staff in contact with the patient
241 prior to endotracheal intubation (Consultant anaesthetist, anaesthetic trainee, and operative

242 department practitioner wearing full PPE) and a 20-minute period before other theatre staff

243 can enter the theatre and start to allow the air in theatre to be recycled to reduce the viral

244 load. This practice precaution was to protect staff members from undiagnosed infection as

245 well as to protect patients from staff given the fact that staff were not routinely tested for this

246 virus.

247

248 RESULTS

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249 A total of 189 patients with aortovascular conditions were admitted to the 19 participating

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250 centres between the 1st March and the 20th May 2020. There were 88 patients presented with

251 an AAS and were the focus of this sub-study.

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253 The AAS were categorised per subtypes: aortic dissection (n= 79, 89.8%), intramural
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254 haematoma (n= 7, 7.9%) and penetrating aortic ulcer (n= 2, 2.3%) and, by anatomical

255 locations: DeBakey I (n= 71, 81 %), DeBakey II (n= 7, 8 %) and DeBakey III (n= 10, 11.4
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256 %). (Figure 1)

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257

258 Surgically treated group

259 A total of seventy-nine patients (89.8%) were treated with surgery.

260 Mean age of this cohort was 62 years (range 29 – 83 years) and 32.9% (n= 26) were females.

261 The surgical procedures performed were: aortic valve and ascending aorta replacement (n=

262 6), aortic root replacement (n= 32), ascending aorta and hemiarch replacement (n= 23), total

263 arch replacement (n= 18), frozen elephant trunk repair of descending thoracic aorta (n= 7),

264 descending thoracic aorta replacement (n= 4) and TEVAR (n= 2).
265 Surgery was offered predominantly as emergency during the same day of the admission (n=

266 55, 69%) or the following day (n= 12, 15.2%). In another 12 cases the operation was

267 performed within 15 days of the admission (mean 7.4 days, range 2 -15 days) due to

268 progression of the presenting disease (i.e. expanding intramural haematomas or penetrating

269 ulcers, complicated DeBakey III aortic dissection), the need for surgical planning (i.e.

270 debranching + TEVAR) or waiting for the COVID-19 screening results in urgent patients.

271

272 In-hospital mortality was 25.3% (n= 20), with a 10.1% rate of intraoperative deaths (n= 8).

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273 Cause of death were categorized as follows: Cardiac (n= 9, 45%), multiorgan failure (n= 5,

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274 25%), stroke (n= 3, 15%), abdominal ischaemia (n= 2, 10%) and aortic rupture (n=1, 5%)

275
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Postoperative complications included: 13.9% postoperative stroke – 11.4% permanent and
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276 2.3% temporary, 16.5% rate of haemofiltration and 10.1% rate of tracheostomy. Mean length
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277 of mechanical ventilation time was 71.5 hours (30 min – 53 days) and mean length of ITU
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278 stay was 4.8 days (2 hours – 53 days).

279
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280 Non-surgical treatment group

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281 A total of 9 patients were not managed surgically due to a variety of reasons.

282 Three patients were accepted for emergency surgery but died either waiting for transfer or en

283 route to the specialised centre or during the anaesthetic induction due to aortic rupture and

284 cardiac tamponade. Mean age was 63.3 years (range 45 - 81 years)

285 Five patients were denied emergency surgery due to clinical complexity. Three of them had

286 history of previous cardiac or aortic surgery and one of them had signs of COVID-19 on the

287 preoperative CT scan. Mean EuroScore II was 16.9%. Two patients were discharged alive,

288 hence the mortality for this group was 60%.

289 Another patient was admitted with a non-complicated DeBakey III aortic dissection and did

290 not require surgical treatment. He was diagnosed of COVID-19 during the hospital admission

291 but did not develop any symptoms or respiratory complications and was discharged home.

292

293 Regional and temporal variation in presentation of acute aortic syndromes

294 There was a clear regional variation in the presentation of the AAS (Table 3), with the

295 London region accumulating the highest number of cases, even exceeding the pre-pandemic

296 activity. This variation is due to the creation of the Pan London Emergency Cardiac Surgery

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297 (PLECS) Service, that concentrated all the cardiac and aortic surgical activity for the region

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298 in two of the participating centres (St Bartholomew’s Hospital and Brompton and Harefield

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NHS Trust) designed as COVID-19 free-environments. [11] (Figure 2)
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300 The majority of regions have managed to maintain the same activity compared to the pre-
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301 pandemic period. (Figure 3)

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303 There was a clear impact of the start of the lockdown in the UK, with the no AAS being
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304 admitted to hospital during the first week of the lockdown, with the activity exponentially
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305 increasing immediately after and reaching a plateau by the end of April 2020. (Figure 4)

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307 COVID-19 patients

308 A total of seven patients were diagnosed of COVID-19 disease in the peri-operative period.

309 Five were diagnosed in the postoperative period, having been operated with unknown

310 COVID-19 status due to the clinical emergency. The diagnosis of COVID-19 with positive

311 swab was made between postoperative day 2 and 24 (mean day 10). Only one of these

312 patients required prolonged mechanical ventilation but there was no COVID-19-related

313 mortality.
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315 One patient had signs of COVID-19 disease in the preoperative CT despite being

316 asymptomatic and swab negative. He required reintubation and ventilation 7 days after

317 surgery and died of respiratory failure.

318

319 The last patient who tested positive for COVID-19 on admission was treated conservatively

320 due a non-complicated DeBakey III aortic dissection and did not develop any COVID-19-

321 related complications.

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323 DISCUSSION

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325 COVID-19 pandemic affected healthcare services to an unprecedented scale globally. In the
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326 UK the NHS was re-organised across all regions with the guidance of Public Health England
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327 and the Central Government, reducing or even stopping the elective surgical activity in most

328 of the regions after the declaration of the lockdown on 23rd March 2020. [7, 10]
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329
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330 There was a clear impact of the start of the lockdown, with no AAS being admitted to

331 hospital during the first week of the lockdown. This reflects the fear and anxiety of the

332 general population, not presenting their illness to A&E services. Although there was an

333 exponential increase in the AAS admission during the following weeks in April, it has taken

334 3 weeks before activity reaching to a pre-lockdown level in UK.

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336 In London, in comparison to the pre-pandemic period, overall the service provision for AAS

337 has been maintained by concentrating all the aortic surgical activity for the region as part of

338 the Pan London Emergency Cardiac Surgery (PLECS) Service [11]. However, the activity in
339 the majority of individual centres were just below the number of AAS cases operated during

340 the same equivalent period last year. This was also supported by the adoption of the modified

341 clinical guidelines for patient selection and indications for surgery [1-4, 6]. This has protected

342 access of patients with aortovascular conditions for emergency and urgent surgery. It has

343 certainly posed a challenge to achieve a balance between protection the AAS patients versus

344 protection of NHS for the rest of the population.

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346 The result of the COVID-19 screening was not awaited in the majority of the AAS patients,

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347 as it was considered that the risk of mortality while waiting for the swab results exceeded the

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348 risk of developing COVID-19-related complications in the immediate post-operative period.

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[5] However, the number of patients in this cohort diagnosed with COVID-19 in the
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350 immediate post-operative period was minimal (n= 7), with the majority of those who were
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351 diagnosed in the early weeks of the study and at least one week after the operation, whilst
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352 already in contact with the general population. There was no COVID-19- related mortality in

353 this group. Most likely explanation for this, is after the declaration of the lockdown the
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354 patients presenting in hospital with AAS were already isolating at home and were shielded in
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355 hospital only in contact with staff wearing full PPE measures, and those factor contributed to

356 the low rate of post-operative COVID-19 infection compared to other surgical series. [12]

357

358 The proportion of patients with AAS treated surgically during this period of the pandemic

359 reached almost 90%, against initial predictions where planned surgical activity could have

360 been severely affected by lack of intensive care beds, shortage of intensive care nurses, the

361 fear of the healthcare professionals to expose themselves to aerosol-generated-procedures or

362 the uncertainty of level of protection ensured by PPE measures.

363
364 During this early part of COVID-19 Pandemic, there were shortage of supply for PPE in

365 NHS hospitals. There has been uncertainty in the level of protection provided by PPE for

366 both patients as well as healthcare workers. Moreover, operating such long surgical

367 procedures wearing full PPE in theatres with restricted staff flow, has significant impact on

368 the comfort zone of the team as a whole. The effect of FFP3 masks (and with surgical mask

369 as an additional outside layer), and visors on the routine team communication as well as

370 physical exhaustion of staff cannot be underestimated.

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372 Surgical mortality of this cohort was 25%, which is similar to the reported outcomes prior to

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373 the pandemic. [5, 13, 14] This is worthy of note as the multidisciplinary teams operating

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under undue pressure facing potential risk of devastating infection as well as working in
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375 unfamiliar and restricted theatre practices including use of full PPE. Moreover, these AAS
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376 patients were managed in ICU by staff with full PPE and were not allowed to have family
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377 members support as routine. Therefore, it was a notable achievement by the clinical teams

378 that the clinical outcomes for patients with AAS were maintained during this period. There
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379 were a small number of patients (n=9) who were not treated surgically showed a high
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380 mortality (60%) as initially expected. Once again the reasons for turning down patients with

381 AAS for surgery were not related to COVID-19 status or reduction in hospital equipment or

382 staffing, but most commonly due to the complexity of the cases; most of them having had

383 previous cardiac and/or aortic surgery, making an out-of-hours re-do operation very

384 challenging the current mandatory PPE measures.

385

386

387

388 CONCLUSION
389 The service provision for AAS has been maintained during the early months of the COVID-

390 19 pandemic in the UK by significant restructuring of NHS, with a very low rate of surgical

391 turn down and COVID-19-related complications.

392 Although most patients were operated on an unknown COVID-19 status, due to the

393 devastating natural history of condition outweighed over the risk of post-operative

394 respiratory-related complications, only a minority of patients developed COVID-19 disease

395 in the post-operative period and that did not influence outcomes. The findings from this study

396 indicates that with an appropriate precaution, emergency surgical treatment can be provided

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397 to patients with AAS with good outcomes during COVID-19 Pandemic.

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417 TABLES AND FIGURE LEGENDS

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n / mean (range) %

Age 62 (29 - 83) -

Female sex 26 32.9

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Hypertension 59 74.7

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Diabetes 6 7.6

Hypercholesterolaemia 12 15.2

COPD 7
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Creatinine 97.7 (42 - 288) -
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Dialysis 1 1.3

Ex-smoker 12 15.2
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Current smoker 13 16.5

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Previous stroke 2 2.5

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Previous TIA 4 5.1

Peripheral vascular disease 7 8.9

Prior myocardial infarction 5 6.3

Prior PCI 1 1.3

Atrial fibrillation 8 10.1

Poor EF 3 3.8

Moderate EF 6 7.6

Prior cardiac surgery 7 8.9

Prior aortic surgery 5 6.3

Prior endovascular treatment 2 2.5

EuroScore II 9.6 (1.8 - 40.8) -

419 Table 1. Demographics and pre-operative risk factors. COPD: chronic obstructive pulmonary

420 disease; EF: ejection fraction; PCI: percutaneous coronary intervention; TIA: transient

421 ischaemic attack.

422

n %

Intraoperative death 8 10.1

Hospital death 20 25.3

Reintubation 5 6.3

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Tracheostomy 8 10.1

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Bleeding/Tamponade 9 11.4

GI bleeding 0 0.0

Mesenteric ischaemia 2
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Stroke 11 13.9
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Myocardial infarction 0 0.0

Renal failure 18 22.8

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Haemofiltration 13 16.5
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Atrial fibrillation 26 32.9

423 Table 2. Postoperative complications. GI: gastrointestinal; ITU: intensive therapy unit.
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424

CENTRE PANDEMIC PRE-PANDEMIC

ACTIVITY ACTIVITY

St Bartholomew’s Hospital 27 (34.2%) 14 (17.5%)

Royal Brompton and Harefield NHS Trust 8 (10.1%) 6 (7.5%)

Hammersmith Hospital 0 3 (3.7%)

Royal Sussex County Hospital 1 (1.3%) 5 (6.2%)

University Hospital Southampton 6 (7.6%) 5 (6.2%)

John Radcliffe Hospital 6 (7.6%) 6 (7.5%)

Queen Elizabeth Hospital 0 3 (3.7%)

 University Hospital Coventry 1 (1.3%) 2 (2.5%)

Royal Stoke University Hospital 1 (1.3%) 0

Glenfield Hospital 2 (2.6%) 1 (1.2%)

Liverpool Heart and Chest Hospital 7 (8.9%) 9 (11.2%)

Blackpool Victoria Hospital 4 (5.1%) 2 (2.5%)

Sheffield Teaching Hospital 6 (7.6%) 3 (3.7%)

Castle Hill Hospital 2 (2.6%) 2 (2.5%)

Freeman Hospital 5 (6.3%) 4 (5%)

James Cook University Hospital 1 (1.3%) 2 (2.5%)

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Royal Infirmary of Edinburgh 3 (3.4%) 4 (5%)

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Aberdeen Royal Infirmary 0 1 (1.2%)

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Royal Victoria Hospital Belfast -p 3 (3.4%) 4 (5%)

Table 3. Number of patients with acute aortic syndromes operated in each of the participating
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426 centres during the study period (Pandemic activity) and during the equivalents months prior
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427 the pandemic (March-May 2019; Pre-pandemic activity).

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428
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429 Figure 1. Number of patients that presented with an acute aortic syndrome to the participating
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430 centres and were included in the study, according to the DeBakey anatomical classification:

431 DeBakey I (affecting the ascending aorta, arch and descending aorta, n= 71), DeBakey II

432 (affecting only the ascending aorta, n= 7) and DeBekay III (confined to the descending aorta,

433 n= 10). ©Servier Medical Art

434

435 Figure 2. Geographical variation in presentation of acute aortic syndromes to hospital during

436 the study period in the 19 participating centres in the United Kingdom. The graded colours

437 represent the number of patients with acute aortic syndromes that were admitted to hospital

438 for assessment and/or surgical treatment according each geographical region. The areas

439 displayed in grey were the regions covered by centres not contributing to the study.
440

441 Figure 3. Geographical variation in presentation of acute aortic syndromes to hospital in the

442 19 participating centres in the United Kingdom during the equivalent months to the study

443 period but the previous year (2019). The graded colours represent the number of patients with

444 acute aortic syndromes that were admitted to hospital for assessment and/or surgical

445 treatment according each geographical region, showing similar activity when compared to the

446 pandemic period displayed in Figure 2. The areas displayed in grey were the regions covered

447 by centres not contributing to the study.

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448

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449 Figure 4. Time variation in presentation of acute aortic syndromes to hospital during the

450
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study period in the 19 participating centres in the United Kingdom. The vertical yellow arrow
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451 marks the start of the lockdown in the UK. The blue line displays the weekly number of
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452 patients with acute aortic syndromes admitted to the participating centres, noticing a clear
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453 reduction after the start of the lockdown with a progressive recovery of the activity in the

454 following weeks. The orange line displays the mortality of patients with acute aortic
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455 syndromes admitted to hospital. Below the x-axis, there is a numerical display of the overall
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456 number of deaths due to COVID-19 in the UK weekly. Note the exponential increase on

457 COVID-19 deaths coincides with a reduction of presentation in aortic syndromes.

458

459 Figure 5. Graphical abstract summarising the study. This was a UK multicentre study with 19

460 partipating aortic centres to assess access to emergency treatment for AAS patients during the

461 early months of the COVID-19 pandemic in the UK. A total of 88 patients were analysed and

462 90% of them underwent surgery, with similar outcomes to pre-pandemic times. Despute the

463 COVID-19 screening was not awaited before emergency surgery was offered, only 7 patients

464 developed COVID-19 in the postoperative period and that was not translated into mortality.
465 Access to emergency treatment and surgical outcomes for AAS were maintained despite the

466 extensive health care restructuring during the COVID-19 pandemic.

467

468 Figure 6. Graph showing the trend in mortality due to COVID-19 in the UK displayed

469 weekly (red line) and the surgical mortality for AAS operated on during the same period of

470 time in the study participating centres (orange line). The lines cross-over on the week of the

471 16th March 2020, corresponding with the start of the lockdown in the UK, when the number

472 of COVID-19 cases started to increase exponentially and the AAS activity decreased initially

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473 due to the reduced presentation to emergency departments. Both curves reached a peak

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474 around mid of April to descend in a parallel way after that. Note that he scale for the COVID-

475
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19 mortality has been adapted and has to be multiplied x100.
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476
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477
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CENTRE PANDEMIC PRE-PANDEMIC

ACTIVITY ACTIVITY
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St Bartholomew’s Hospital 27 (34.2%) 14 (17.5%)

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Royal Brompton and Harefield NHS Trust 8 (10.1%) 6 (7.5%)

Hammersmith Hospital 0 3 (3.7%)

Royal Sussex County Hospital 1 (1.3%) 5 (6.2%)

University Hospital Southampton 6 (7.6%) 5 (6.2%)

John Radcliffe Hospital 6 (7.6%) 6 (7.5%)

Queen Elizabeth Hospital 0 3 (3.7%)

University Hospital Coventry 1 (1.3%) 2 (2.5%)

Royal Stoke University Hospital 1 (1.3%) 0

Glenfield Hospital 2 (2.6%) 1 (1.2%)

Liverpool Heart and Chest Hospital 7 (8.9%) 9 (11.2%)

Blackpool Victoria Hospital 4 (5.1%) 2 (2.5%)

 Sheffield Teaching Hospital 6 (7.6%) 3 (3.7%)

Castle Hill Hospital 2 (2.6%) 2 (2.5%)

Freeman Hospital 5 (6.3%) 4 (5%)

James Cook University Hospital 1 (1.3%) 2 (2.5%)

Royal Infirmary of Edinburgh 3 (3.4%) 4 (5%)

Aberdeen Royal Infirmary 0 1 (1.2%)

Royal Victoria Hospital Belfast 3 (3.4%) 4 (5%)

478 Table 3. Number of patients with acute aortic syndromes operated in each of the participating

479 centres during the study period (Pandemic activity) and during the equivalents months prior

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480 the pandemic (March-May 2019; Pre-pandemic activity).

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481

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483
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484 REFERENCES
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485

486 1. COVID-19: Guidance for Triage of Non-Emergence Surgical Procedures. American

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487 College of Surgeons. www.facs.org. Published online 17th March 2020.

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488 2. Cardiac Surgery and the COVID-19 Outbreak: what does it mean?

489 www.pcronline.com. Published online 25th March 2020.

490 3. Hasan A, Arosra RC, Adams C, Boschard D, Cook R, Gunning D et al. Cardiac

491 surgery in Canada during the COVID-19 pandemic: a guidance statement from the

492 Canadian Society of Cardiac Surgeons. Can J Cardiol 2020

493 4. COVID-19 virus and vascular surgery. The Vascular Society for Great Britain and

494 Ireland. www.vascularsociety.org.uk. Published online 20th March 2020

495 5. Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Di Eusanio M, Sechtem U et

496 al. Insights from the International Registry of Acute Aortic Dissection: a 20-year

497 experience of collaborative research. Circulation 2018;137:1846-60.

498 6. Barts Protocol for Surgery in Aortovascular patients during the COVID-19 Pandemic.

499 www.scts.org Published online 2nd April 2020

500 7. COVID-19: guidance for health professionals from Public Health England and the

501 Department of Health and Social Care. www.gov.uk. Published online 10th January

502 2020.

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503 8. Pan-London Emergency Cardiac Surgery Standard Operating protocol during

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504 COVID-19 pandemic. www.scts.org Published online 27th March 2020

505
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9. St Bartholomew’s Hospital Theatre Standard Operating protocol for COVID-19.
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506 www.scts.org Published online 8th April 2020
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507 10. Coronavirus (COVID-19): personal protective equipment (PPE). www.gov.uk.

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508 Published 10th April 2020

509 11. Hussain A, Balmforth D, Yates M, Lopez-Marco A, Rathwell C, Lambourne J et al.

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510 The Pan London Emergency Cardiac Surgery service: Coordinating a response to the
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511 COVID-19 pandemic. J Cardiac Surg 2020;1-7.

512 12. COVIDSurg Collaborative. Mortality and pulmonary complications in patients

513 undergoing surgery with perioperative SARS-CoV-2 infection: and international

514 cohort study. Lancet 2020.

515 13. Richens D. Cardiothoracic surgery GIRFT Programme National Specialty report.

516 www.gettingitrightfirsttime.co.uk 2018

517 14. Bottle A, Mariscalco G, Shaw MA, Benedetto U et al. Unwarranted variation in the

518 quality of care for patients with diseases of the thoracic aorta. J Am Heart Assoc

519 2017; 6(3):e004913

 n / mean (range) %

Age 62 (29 - 83) -

Female sex 26 32.9

Hypertension 59 74.7

Diabetes 6 7.6

Hypercholesterolaemia 12 15.2

COPD 7 8.9

Creatinine 97.7 (42 - 288) -

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Dialysis 1 1.3

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Ex-smoker 12 15.2

Current smoker 13 -p 16.5

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Previous stroke 2 2.5

Previous TIA 4 5.1

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Peripheral vascular disease 7 8.9

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Prior myocardial infarction 5 6.3

Prior PCI 1 1.3

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Atrial fibrillation 8 10.1

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Poor EF 3 3.8

Moderate EF 6 7.6

Prior cardiac surgery 7 8.9

Prior aortic surgery 5 6.3

Prior endovascular treatment 2 2.5

EuroScore II 9.6 (1.8 - 40.8) -

Table 1. Demographics and pre-operative risk factors. COPD: chronic obstructive pulmonary

disease; EF: ejection fraction; PCI: percutaneous coronary intervention; TIA: transient

ischaemic attack.
 n %

Intraoperative death 8 10.1

Hospital death 20 25.3

Reintubation 5 6.3

Tracheostomy 8 10.1

Bleeding/Tamponade 9 11.4

GI bleeding 0 0.0

Mesenteric ischaemia 2 2.5

Stroke 11 13.9

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Myocardial infarction 0 0.0

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Renal failure 18 22.8

Haemofiltration

Atrial fibrillation
13

26
-p 16.5

32.9
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Table 2. Postoperative complications. GI: gastrointestinal; ITU: intensive therapy unit.
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CENTRE PANDEMIC PRE-PANDEMIC

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ACTIVITY ACTIVITY
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St Bartholomew’s Hospital 27 (34.2%) 14 (17.5%)

Royal Brompton and Harefield NHS Trust 8 (10.1%) 6 (7.5%)

Hammersmith Hospital 0 3 (3.7%)

Royal Sussex County Hospital 1 (1.3%) 5 (6.2%)

University Hospital Southampton 6 (7.6%) 5 (6.2%)

John Radcliffe Hospital 6 (7.6%) 6 (7.5%)

Queen Elizabeth Hospital 0 3 (3.7%)

University Hospital Coventry 1 (1.3%) 2 (2.5%)

Royal Stoke University Hospital 1 (1.3%) 0

Glenfield Hospital 2 (2.6%) 1 (1.2%)

Liverpool Heart and Chest Hospital 7 (8.9%) 9 (11.2%)

Blackpool Victoria Hospital 4 (5.1%) 2 (2.5%)

Sheffield Teaching Hospital 6 (7.6%) 3 (3.7%)

Castle Hill Hospital 2 (2.6%) 2 (2.5%)

Freeman Hospital 5 (6.3%) 4 (5%)

James Cook University Hospital 1 (1.3%) 2 (2.5%)

Royal Infirmary of Edinburgh 3 (3.4%) 4 (5%)

Aberdeen Royal Infirmary 0 1 (1.2%)

Royal Victoria Hospital Belfast 3 (3.4%) 4 (5%)

Table 3. Number of patients with acute aortic syndromes operated in each of the participating

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centres during the study period (Pandemic activity) and during the equivalents months prior

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the pandemic (March-May 2019; Pre-pandemic activity).
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