Telemedicine in cardiovascular surgery during COVID‐19 pandemic: A systematic review and our experience

Abstract Objective The SAR‐COV‐2 pandemic has had an unprecedented effect on the UK's healthcare systems. To reduce spread of the virus, elective treatments and surgeries have been postponed or canceled. There has been a rise in the use of telemedicine (TM) as an alternative way to carry outpatient consultations. This systematic review aims to evaluate the extent to which TM may be able to support cardiac and vascular surgery patients in the COVID‐19 era. Methods We looked into how TM can support the management of patients via triaging, preoperative, and postoperative care. Evaluations targeted the clinical effectiveness of common TM methods and the feasibility of applying those methods in the UK during this pandemic. Results Several studies have published their evidence on the benefit of TM and its benefit during COVID‐19, the data related to cardiovascular surgery and how this will impact future practice of this speciality is emerging and yet larger studies with appropriate timing of outcomes to be published. Conclusion Overall, the use of virtual consultations and remote monitoring is feasible and best placed to support these patients via triaging and postoperative monitoring. However, TM can be limited by the need of sophisticated technological requirement and patients’ educational and know‐how computer literacy level.

cases, COVID-19 can result in acute respiratory distress syndrome or organ failure, 1-2 leading to some individuals being admitted to intensive care units. The high reproductive value of COVID-19 combined with the limited treatment options or vaccine against the disease has led to an overrun of the UK's healthcare systems. [6][7] The COVID-19 pandemic has influenced the conduct of society: as of 23 March 2020, the UK government announced a lockdown in which strict social distancing measures were to be followed by UK residents. 7 New guidelines meant that residents could only leave for essential work, food shopping, and daily exercise. The lockdown also saw the shutdown of many entertainment and nonessential businesses such as restaurants, cinemas, and concert halls. Since then, as of 22nd May, the lockdown rules in the UK have been drastically relaxed and as the reproductive value fell under 1 8 and lockdown measures across the globe have been less restrictive as the economy and society seeks to find a new "normal.".

| COVID-19 and the impact on UK healthcare systems
The impact of the COVID-19 pandemic on healthcare systems has been equally as disruptive. 7 Critical care systems across western healthcare were originally overwhelmed by the outbreak. Over 250 000 volunteers and 5000 retired National Health Service (NHS) staff were recruited to help deal with the effects of the pandemic. 9 There have been detrimental effects on other aspects of healthcare: regular cancer screenings were paused, 10 and elective surgeries postponed in an attempt to contain the outbreak. [11][12] As of recently, guidelines have been released to start phasing these procedures back into practice, [13][14] however, it will be sometime before the impending backlog of surgeries is resolved. 10 The cancellation of all except essential surgeries, together with guidelines to minimize contact between patients and physicians, had an impact on the practice of all major surgical specialities. Difficult decisions must be made where physicians must weigh up the risk of vulnerable patients being exposed to SARS-COV-2, vs the risk of delaying their surgical treatments. Because of this, there has been a call for the use alternative avenues, such as telemedicine (TM), that may be able to play a role in alleviating some of the impact of COVID-19 by bridging the gap between patients and surgeons. 15

| Introduction to TM
TM refers to the use of information and telecommunication technologies to facilitate the remote provision of healthcare services. While the origin of TM can be traced back several hundred years, the modern form of TM was established in the 20th century, which saw the rapid evolution of increasingly sophisticated communication technology. 16 A milestone in TM was reached when in the 1960s, the National Aeronautics Space Administration, used satellite communication in a spaceflight mission to enable doctors on earth to track the physiological changes of astronauts in space. 17 The advent of the telephone, television, and two-way audio and video communication channels played major roles in expanding the reach of TM. Now in more recent times, mobile technology and the internet have emerged and become mainstays, making TM remarkably more accessible in the modern era. 18 The main categories of TM include real-time communication (synchronous), for example, videoconferencing for online consultation and diagnosis; store-andforward communication (asynchronous), for example, electronic transfer of clinical data such as images or medical history; and remote monitoring, which enables doctors to remotely observe and track a patient's real-time clinical signs. 19 The World Health Organization has highlighted the benefits of the use of rapidly developing information technologies in medicine, due to the potential scope of providing increasingly convenient, time-saving, and perhaps more cost-efficient doctor-patient interaction. 20 While it has been argued that TM cannot always be an adequate substitute for traditional face-to-face healthcare and physical examination, 21 the advantage of the remote delivery of health services becomes clearly apparent in situations where the point of contention is the distance between the patient and physician. For example, TM has often been vital in linking rural and medically underserved areas to GPs and specialists. 17,22 Similarly, in the case of the current SARS-Cov-2 crisis, maintaining social distancing is vital to the suppression of the pandemic, and with the additional factor of the growing strain on NHS resources, these conditions have brought the value of TM to the forefront of medical practice.

| TM use in the UK
Whilst TM has always had strong support on paper, the UK healthcare community at large has been slow in taking advantage of the resource. TM has had a limited history of use in the UK with regards to secondary and tertiary care, however, the current conditions have forced healthcare service providers across all frontiers to adapt to TM on an emergency basis. 23 The NHS and the GMC have released resources and guidelines to assist both primary and secondary care clinicians in implementing online consultations where possible. [23][24][25] TM has already been adapted into primary care, with telephone consultations and home-monitoring systems already are in regular use in general practice, however, with the adjustments made to secondary and tertiary care services in the COVID-19 era, it is unclear as to whether TM can meet the needs of complex specialities such as cardiovascular surgery. Thus, we will explore whether, in the COVID-19 era, TM can meet the healthcare demands of cardiac and vascular surgery specialities.

| Evaluating the usefulness of TM in cardiovascular surgery patients
For cardiac and vascular surgery, essential to the management of new and existing patients is effective triaging on the basis of the NHS guidelines for surgical prioritization during the pandemic. 26

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To practice healthcare within the social distancing guidelines, it is necessary to evaluate the potential of TM as a platform through which triaging and preoperative investigations can be remotely carried out in the context of cardiac surgery and vascular surgery.
A major aspect of the research surrounding the use of TM in cardiovascular settings has involved remotely-based cardiac specialists providing expert diagnoses and assessment of patient condition from a distance, using patient history, live biodata, and cardiac imaging. Remote analysis of echocardiograms via real-time teleconsultation was used to triage patients for cardiac surgery with good outcomes, 27,28 and the remote interpretation of results from a hand held ultrasound proved to be beneficial in the diagnosis of most cardiovascular diseases (CVDs) in comparison to standard echocardiography. 29 Specialist teleconsultations of angiograms have also demonstrated accuracy in diagnosis and referral to procedures such as coronary artery bypass graft (CABG). 27,30 Similarly remote transmission of cardiac magnetic resonance imaging has been successfully used to assess congenital heart disease in children. 31 However, the use of cardiac imaging in remote diagnosis requires the availability of imaging equipment and trained technicians to perform the scans before the images can be interpreted by a remote specialist. As the current crisis situation calls for minimum contact between patients and healthcare personnel, this category of TM technology for managing cardiac surgery candidates is of limited use amidst COVID-19.
The electrocardiogram (ECG) is amongst the most pivotal tools used in the management of cardiac conditions, and has seen significant development over the years. Since 1906, 32 substantial effort has gone into investigating the efficiency of a tele-ECG interpretation, and most studies have found it to be just as effective, if not superior to a regular 12-lead ECG, in the detection and triaging of patients with myocardial infarction and other complications. [33][34][35] However, for the purpose of use during a pandemic like COVID-19, tele-ECG home-monitoring technologies are more relevant. In more recent years, the contribution of mobile health (mhealth) technologies has transformed remote monitoring through the introduction of mobile phone applications that can transmit patient vitals straight to physicians, have patient-friendly user interfaces, and are easily accessible. Single lead portable ECG devices such as the AliveCor Heart Monitor record ECG traces and transmit them to a mobile application with which they are paired, and can then be viewed by specialists. 36 Such devices have been useful in detecting arrhythmias, 37,38 and thus have the potential to be used during COVID-19 to remotely monitor heart rhythms of surgical candidates.
A significant amount of research has gone into investigating the role of portable and wireless home-monitoring technologies such as AliveCor, in the remote monitoring of patients with cardiac conditions.
One study used the ASCOLTA telemonitoring system to wirelessly collect biometric data from heart failure (HF) patients, including ECG, respiratory rate, and oxygen saturation (SpO 2 ), along with questionnaires on general health data, and found that the combined information allowed cardiologists to effectively determine a patient's health status remotely and with high efficacy. 39 Wireless wearable sensors are now increasingly available in the market, for measuring vital signs like heart rate (HR) and blood pressure (BP). One group developed a telemonitoring system connecting wearable sensors via Bluetooth to android mobile phones, which would send real-time clinical data to a web interface accessed by doctors. Thus physicians were able to monitor the HR, BP, and body temperature of cardiac patients in realtime, and after a comparison against data collected from traditional devices, the data from the wearable technology were deemed accurate.
There was also an alarm system set up to warn of any changes or abnormalities detected. 40 More recently another similar study also managed to record real-time ECGs and SpO 2 along with HR, BP, and temperature, via wearable circuits and developed a mobile phone application to receive and transmit the data to doctors. 41 BP/HR monitors, pulse oximeters, scales, and ECG monitors are devices generally employed in the tele-management of HF, which patients are taught to use at home, and the data from these are wirelessly transmitted to healthcare staff. 42 Several HF trials such as the TIM-HF2 43 and BEAT-HF 44 have used these telemonitoring styles. Patient self-monitoring has also lead to favorable outcomes in BP reduction compared to conventional follow-ups, 45 and one study also showed that physicians were able to make more frequent treatment adjustments in the self-monitoring group, compared to the conventional group. 46 Telemonitoring was also useful in reducing rehospitalization within 30 days of an acute MI. 47 The DICE intervention was effectively carried out using remote biometrics monitoring to track the post-CABG surgery health status of vulnerable patients, demonstrating that this could be implemented in place of conventional in-person follow-up appointments. 48 While some trials show that superiority of using TM over conventional management may be debatable, the majority of the research indicates that the monitoring of clinical parameters of cardiac patients during COVID-19 is likely to be useful in not only the overall management of the changing health status of patients, but also more specifically in facilitating effective remote presurgical triaging, detecting cardiac deterioration, and managing potential postsurgical complications. Some of the aforementioned HF trials also integrated structured telephone support in patient care, along with telemonitoring, to gather more detailed patient information and receive regular updates. Combined, these TM methods show evidence of reduced hospitalizations, 49 and thus may have benefited during COVID-19 in reducing patient exposure to hospitals which are SARS-Cov-2 hotspots, and in generally reducing doctor-patient contact.
Video consultations, combined with remote monitoring, were also a feasible replacement for standard ambulatory follow-up after cardiac device implantation. 50,51 Moreover, telemonitoring of physiological and haemodynamic data from these implanted devices such as cardiac resynchronization defibrillators has also been extensively studied, as this data can indicate oncoming complications like cardiac decompensations. The IN-TIME trial demonstrated the benefits of the use of such devices in HF patients with implants, in reducing allcause mortality and rehospitalizations. 52 In a similar TELECART study, implant monitoring did not correlate with reduced all-cause mortality, however, it was useful in making timely improvements to patient management and thus could potentially help reduce AJIBADE ET AL.

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hospitalizations. 53 Implanted devices that allow the monitoring of pulmonary artery pressure are also becoming more common, and once again, as demonstrated in the CHAMPION trial, enable physicians to track and make appropriate changes to treatment regimens in CVD patients, reducing hospitalizations and mortality. 54 The feasibility of a home-based cardiac rehabilitation program using TM, to replace the standard in-hospital program for patients who have undergone cardiac surgery (eg, CABG, valvular surgeries), has also been tested. By providing patients with at-home exercise equipment and a one-lead tele-ECG device, and through scheduled telephone and videoconferencing, hospital staffs were able to track patients for any complications, and facilitate effective physiotherapy. 55,56 While patients were still required to make hospital visits through the duration of the programs, these could possibly be minimized in a critical situation such as the current one. However, these programs would then be less suitable to patients with higher complication risks, who may require inhospital facilities and face-to-face support. The FIT@Home study conducted a 12-week home-based exercise training program for cardiac surgery patients, where patient status was tracked using a remote heart-rate monitor and regular telephone support. The results were comparable to a conventional rehabilitation control group, and inperson consultations were minimal throughout the study. However, only patients with low to moderate risk of adverse events were included, thus TM based rehabilitation may not be suitable for higher-risk patients. 57 Postoperative home rehabilitation may also be less than convenient to patients lacking at-home caregivers.
With regards, to vascular surgery, TM has also proved practical A further limitation of TM is that preoperative evaluations are difficult to perform and a full physical examination cannot be conducted over a digital platform. 66 Regardless of these issues, TM is seen to be just as effective as face-to-face consultations 67 when it comes to patient satisfaction and clinical effectiveness regarding triaging, straightforward diagnosis, and postoperative rehabilitation. It is important to remember, however, that TM is always dependant on the availability and workability of the technology needed to power it.    Patient experience has been positive so far and yet the clinicians have not reported any dissatisfaction from such practice.
It is important to reflect that such virtual clinic follow-ups have its own advantage in lacking direct patient contact, therefore, no risk of COVID-19 acquisition, especially vast majority of our cohorts are elderly patients who are at higher risk of acquiring COVID-19.
Nevertheless, virtual follow-up has its own limitations in terms of lack of direct assessment of the clinical condition of the patient through routine examination and inspection of the surgical sites which could potentially lead to missing some manageable conditions as pleural effusion and unstable sternum. The long-term impact of this practice is yet to be identified once this pandemic is over.
Additionally, our routine and ad-hoc urgent multidisciplinary meetings (MDTs) have shifted to be virtual practice through using Microsoft Team application which has not only helped in maintaining social distance during this pandemic but also allowed more people to join the MDT. This practice not only applied for internal MDTs but also to the specialized ones that needed meetings of different specialists from the region to discuss complex cases which, before COVID-19 pandemic, previously required travel of such specialists to a selected unit to meet and discuss such cases. Such initiation has provided convenience, maintained safe social distances, and saved travel times without affecting the decision making process and quality of services offered to patients.

| CONCLUSION AND FUTURE RESEARCH
Overall, in the COVID-19 era, remote monitoring shows the most potential for use in the ongoing crisis. Combinations of regular virtual consultations and remote monitoring of clinical parameters are feasible for cardiac surgery patients and would be useful to assess and triage before surgery. Remote monitoring could also be particularly useful in managing postoperative complications, to help reduce ambulatory visits and rehospitalizations for vascular surgery patients. This is especially vital right now as the social distancing measures are set to stay for the foreseeable future; the utmost priority is to explore the use TM to reduce patient to physician contact as much as possible.
As society and healthcare seek to find a "new normal," greater investments will need to be made in technological gaps around the UK so that the use of TM can become more common. The authors believe that more attention is needed to see how TM can be made more accessible to those best placed to benefit from it. 68 | 2781 In addition to this, a potential future for TM may be the use of telepresence surgery on vascular patients. Telepresence surgery would allow for more socially distanced operations to occur via TM and could benefit patients who cannot risk traveling longer journeys for operations. Whilst preliminary research has shown this type of surgery to be effective on swine, 68 and robotic surgery is more widely accepted in healthcare, more research would be needed to see distanced operations could be applicable to humans and how feasible this surgery could be implemented under the NHS.