COVID-19 FAQs in Pediatric Cardiac Surgery

The world at large and the United States’ health care infrastructure face unprecedented challenges in the COVID-19 pandemic, and the congenital heart disease (CHD) community is no exception. These challenges include potential resource scarcities of equipment, personnel, and blood products. There is also a potential risk of infection to healthcare providers and family members. The relatively small size of the CHD workforce adds another dimension to the challenge, since the rapid spread of COVID-19 could result in programmatic collapse at a moment’s notice secondary to insufficient personnel from infection or quarantine. While many segments of our culture can pause during this period of crisis, pediatric patients’ diseases require continuing care, particularly amongst newborns and infants who often require surgery during a narrow window of time to avoid death and provide for optimal outcomes. The medical community has been overwhelmed with video conferences, webinars and newsletter updates that have covered a broad range of topics. Many of the questions now center on critical care and infectious disease (ID) related issues – screening techniques, preventative measures, treatment options, etc. Crisis management strategies for congenital heart disease have recently been published. The purpose of this review is to succinctly summarize frequently asked questions related to COVID-19 as it relates to children with congenital heart disease.


Introduction
The world at large and the United States' health care infrastructure face unprecedented challenges in the COVID-19 pandemic, and the congenital heart disease (CHD) community is no exception. These challenges include potential resource scarcities of equipment, personnel, and blood products. There is also a potential risk of infection to healthcare providers and family members. The relatively small size of the CHD workforce adds another dimension to the challenge, since the rapid spread of COVID-19 could result in programmatic collapse at a moment's notice secondary to insufficient personnel from infection or quarantine. While many segments of our culture can pause during this period of crisis, pediatric patients' diseases require continuing care, particularly amongst newborns and infants who often require surgery during a narrow window of time to avoid death and provide for optimal outcomes. The medical community has been overwhelmed with video conferences, webinars and newsletter updates that have covered a broad range of topics. Many of the questions now center on critical care and infectious disease (ID) related issues -screening techniques, preventative measures, treatment options, etc. Crisis management strategies for congenital heart disease have recently been published 1 . The purpose of this review is to succinctly summarize frequently asked questions related to COVID-19 as it relates to children with congenital heart disease.
1. What is the role of nasal swab versus serum testing in a child needing heart surgery?
The best test for SARS-CoV2 in the peri-operative setting is a PCR of respiratory secretions. These samples may be from a nasopharyngeal swab, oropharyngeal swab, or sample from the lower respiratory tract (e.g., tracheal aspirate or BAL), if available at your center. PCR testing sensitivity is dependent on viral SARS-CoV2 concentrations at the site of the sample, thus it may be affected by sampling technique, by progression of the disease, and by the test itself. As the disease progresses, viral load tends to decrease in the upper respiratory tract. Serology serum testing for antibodies (IgG) may be available in some centers. However, positive serology will demonstrate prior exposure (or maternal status for neonates) rather than active illness, so is less useful in a peri-operative setting.
https://www.cdc.gov/coronavirus/2019-nCoV/index. html 2 2. What is the optimal pre-operative testing? Is there a role for CT chest scan to look at lungs the day before surgery? If pre-operative testing is used, PCR-based testing of respiratory secretions is the most widely accepted approach. All patients should additionally be screened for symptoms. There are reports demonstrating chest CT abnormalities in adults during asymptomatic/presymptomatic disease; however, the role of chest CT in relation to COVID-19 in children remains undifferentiated at this time. Given lack of evidence, radiation exposure, and potential sedation-requirement in younger children, CT scans should not be used to screen for or diagnose pediatric COVID-19. CT scans should be reserved for other clinical indications based on symptoms. 8. Is there a role for antiviral therapy?
The recommended treatment for COVID-19 is supportive care. In some critically ill children, there may be a role for specific antiviral therapy, though there are no compelling data supporting efficacy of any available antiviral agent at the time of publication.
Remdesivir is an antiviral being studied in adults in several RCTs and may be used in children through single patient expanded access requests. Hydroxychloroquine has been used, but there are increasing safety concerns related to risk of QTc prolongation and still extremely limited efficacy data. Extreme care should be taken in patients at increased risk of prolonged QTc. There may also be a role for convalescent plasma (plasma from patients who have had COVID-19 and now have antibodies) during pediatric critical illness; this therapy is still being studied. The use of corticosteroids is not recommended as it may prolong viral replication.

Summary
Unprecedented times call for unprecedented measures and elite teamwork. Prioritization and appropriate timing of surgery are essential. Continuous collection of evidence during the COVID-19 crisis will help guide decision-making, particularly with regard to critical care and ID-related issues. Practical guidance strategies include ensuring safety and tactics for children with CHD, their families, and all of the healthcare providers involved in their care. The pediatric cardiac surgery team has been marked by unanimity and camaraderie. This cohesive team carries a history notable for collaboration, flexibility, adaptation, and immediate readiness. This assortment of FAQ's and expert answers is yet another constructive strategy to improve pediatric patient care in this time of crisis.