Turn down of acute aortic syndrome cases during COVID‐19: Results from UK multicentre studies

Abstract Objective The coronavirus disease 2019 (COVID‐19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID‐19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic. Methods This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom. Results Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic. Conclusion Services for life‐threatening aortic surgery patients were maintained during the COVID‐19 period through patient selection and timing of surgery. The rate of surgical turn‐down was comparable to published figures despite the challenges faced during the COVID‐19 pandemic.

patients affected by COVID-19, as well as to protect healthy individuals from unnecessary exposure in hospital environments. In the United Kingdom, the majority of the units were prompted to put all elective surgery on hold during March and April 2020, leading to a restructuring in the provision of aortovascular services during the pandemic to protect access to essential emergency treatment. 2 Acute aortic syndromes (AAS) represent a surgical emergency, with a devastating natural history carrying high mortality (1%-2% each hour) if not treated immediately. 3,4 The aim of this study was to establish if AAS patients had unrestricted access to emergency treatment and the outcomes of these patients during the peak of the pandemic.

| METHODS
This is a retrospective analysis of prospectively collected data from a multicentre study with 19 participating aortic centers from the United Kingdom (66% of the aortic units in the country, including the largest specialized aortic centers and covering most of the geographical areas), designed to assess the impact of the COVID-19 pandemic in the delivery of services for aortovascular disease in the United Kingdom between March and June 2020.
The other 15 aortic units declined to participate in the study for different reasons including the inability to provide emergency surgery cover during the COVID-19, insufficient resources to collect the data, and/or individual preferences.
We identified patients who were admitted to specialized aortic units with the diagnosis of AAS and turned down for surgery and clinical outcomes for these patients when compared to the outcomes of the surgical cohort in the same period.

| RESULTS
Between March and June 2020, 95 patients were admitted with a diagnosis of AAS at the participating centers. Seven patients (7.3%) were turned down for surgery. The mean age was 77. 4 years (74-81) and 57% were females. Six patients presented with an acute aortic dissection (five DeBakey I and one DeBakey II) and one with an acute on chronic DeBakey III aortic dissection. Five patients (71%) had undergone prior cardiac surgery.
The rationale for the surgical turn down was based on the following reasons: clinical complexity, frailty or multi-comorbidities, and history of previous cardiac surgery. Only one patient was diagnosed with COVID-19 disease based on radiological finidings of groundglass opacities on the computed tomography scan and therefore the decision of not offering surgery, as COVID-19 considered as an additional increase in his perioperative risk profile.
The mean EuroScore II was 18.9 (4.8-37.0 These patients presented in four different aortic centers, two of them leading aortic centers in volume and expertise. The two leading centers had a turn-down rate of 10% and 12%, while the other two centers turned down 50% and 67% of the AAS referred to them.
The rest of the participating centers did not turn down for surgery any of the referred patients, but no cases with previous cardiac or aortic surgery were admitted to these units during this period.
The natural progression of AAS disease carries an increasing mortality, [3][4][5]  Explanations for the turn down for surgery during the first month were related to the uncertainty and the ability to quantify the additional perioperative risks related to COVID-19 infections, in the context of patients with multiple comorbidities and undergoing a high-risk procedure. There were, however, no surgical turn downs directly related to the relocation of resources due to the COVID-19 pandemic (i.e., shortage of intensive care unit beds or healthcare professionals due to relocation treat respiratory patients).
The international registry of acute aortic dissection reported surgical correction in only 86% of their cohort among the total of 2952 patients presented with acute type A aortic dissection 6 ; it is important to note that our turn-down rate of 7.3% during COVID-19 is reflecting an acceptable figure considering the challenging times of the COVID-19 pandemic. We predicted a higher turn-down rate during the pandemic considering the challenges that the pandemic has posed as highlighted above. formats (e.g., virtual or face to face) and frequency (weekly or biweekly) among the participating centers.

| LIMITATIONS
There are several limitations associated with our study, including the small sample size in this subcohort or patients and the variation in practice among the participating centers.

| CONCLUSIONS
There was no restricted access to treatment for AAS during the early months of the pandemic in the United Kingdom and the outcomes of patients surgically treated were consistent with prepandemic figures.
The surgical turn-down rate for patients with AAS has been lower than expected despite the challenges the pandemic posed and not directly related to COVID-19 status.