Statistical analysis

Standard descriptive statistics were calculated. Data are presented in absolute numbers and percentages. For statistical analysis, we used the software SPSS 21.0.

Comment

Brazil ranks number 6 in the most populated countries according to the worldometer, and Brazilian citizens represents 2.73% of the global population. ¹³ The prevalence of CHD is estimated at 9:1.000 births, which accounts for approximately 25.000 new CHD cases per year in Brazil. ^{Reference Pinto Júnior, Branco and Cavalcante14} The biggest Latin American country is divided into five regions with 27 states, and there are 22 states in which Pediatric and Congenital Heart Surgery is performed. Nevertheless, there is a deficit in response to demand close to half. ^{Reference Pinto, Fraga Mde, Freitas and Croti11}

Brazil is the second most affected country by the pandemic, with more than 12 million cases. ⁵ As in the rest of the world, the Brazilian healthcare infrastructure is also facing a massive challenge with the COVID-19 pandemic, and CHD patients were no exception. Patients avoided going to medical facilities due to fear of catching the deadly condition or as an unintended consequence of “stay-at-home” orders.

This delay in seeking medical care has drastically decreased emergency room visits for non-COVID-19 conditions such as appendicitis, heart attack, stroke, and other diseases, including CHD decompensations. Elective surgeries were postponed or cancelled, including those for CHD. Due to limited resources as staff and supplies needed for adults, the Health Ministry and the Brazilian Society of Cardiovascular Surgery recommended cancelling elective surgery that was the major surgical volume. ⁹ It was not just a local recommendation, but it was a global advice. ^{Reference Stephens, Dearani and Guleserian8}

In the present scenario, it is essential to understand the pandemic’s impact on the national Pediatric and Congenital Heart Surgery programmes that are known to be insufficient to meet CHD demand.

Almost all Brazilian centres were affected in some way by the pandemic, both in terms of the volume and complexity of the cases treated. In 17.4% of the centres, less than one-quarter of the staff caring CHD remained active.

At the beginning of the pandemic, there were no screening protocols for two reasons: 1 – unknown disease; and 2 – logistical issue, low availability of tests. ^{Reference Miana, Manuel and Caneo15}

Institutional protocols have been established to prevent infection of patients both in the pre- and post-operative periods. In the most extensive Brazilin Pediatric and Congenital Heart Surgery programme, the protocol suffered constant improvements as the pandemic evolved, but a significant impact on surgical volume and case-mix could not be avoided. ^{Reference Miana, Manuel and Caneo15}

Many protocols and guidelines have been proposed worldwide to establish a perioperative management issue for patients with CHD. ^{Reference Protopapas, Rito and Vida12,Reference Atalay, Soran Türkcan and Taşoğluİ16,Reference Hiremath, Yadava and Meharwal17} The similarity of the protocols is pre-operative screening for COVID-19, separation of wards between COVID-19-free patients, and suspects avoiding contamination risks. Nevertheless, contamination risks apparently came from all over the places, like patients relatives, healthcare workers, and other patients.

During the peak of the pandemic’s first wave between April and June 2020, the most significant impact was observed. There was a need to offset the expense of supplements, and hospital beds were saved for potential COVID-19 patients that could be useful at a time when little was known about the new disease. ⁴

Accordingly, we observed that Brazilian centres were mostly impacted between April and June 2020. Although there was a declined number of cases and deaths since July 2020, one-third of Brazilian programmes have not had their volume back to normal as of November 2020.

Reduction in surgical volume and post-operative contamination risks apparently had nothing to do with the centres size or volume. It seemed that the higher the contamination rate in the community, the worse the situation inside the hospital. Said that, most post-operative contaminations occurred in the north of Brazil (Amazon area) and in São Paulo, respectively, the lowest and higher income areas in Brazil.

In December 2020, many countries around the globe, including Brazil, were struck by a devastating pandemic second wave with an increased number of cases and deaths and its impact is still to be understood. ¹⁸

As expected, the present study demonstrated a significant COVID-19 pandemic impact on Brazilian Pediatric and Congenital Heart Surgery programmes such as surgical volume reduction and increasing complexity of the surgical case-mix. Along with all these implications, a considerable increment in mortality was observed in over one-third (37%) of the centres. Elevated mortality associated with the pandemic period may cause moral distress and anxiety in healthcare workers. ^{Reference Wahlster, Sharma and Lewis19}

Patients with CHD are known to be at increased risk of complications with COVID-19. ^{Reference Kruglikov, Shah and Scherer20} In our study, we observed a high number of infected patients in the post-operative period (48 patients) with a significant mortality rate of 45.8%. There were all sorts of presentations, from positive and asymptomatic patients to hypoxemic and respiratory insufficiency due to COVID-19.

It is hard to give a precise information regarding the cause of death in these patients, because autopsies are not being performed in Brazil since the pandemic beginning. However, as far as we could collect from the data, post-operative contaminated patients who survived had mild or asymptomatic presentations.

It is reported that inflammation adds an additional risk of complications in patients infected by SARS-CoV-2. Obese and diabetic patients are exhibiting higher mortality rates. ^{Reference Kruglikov, Shah and Scherer20} Surgical trauma associated with cardiopulmonary bypass enhances the inflammatory response ^{Reference Manuel, Miana and Guerreiro21} and may explain these high mortality rates observed in COVID-19-infected patients in Pediatric and Congenital Heart Surgery post-operative.

At the beginning of the pandemic, Nepogodiev et al. demonstrated 34% mortality rate in cardiac surgery patients infected by SARS-COV-2 in the perioperative period. When pulmonary complications occurred, 30-day mortality went up to above 90%. ^{Reference Nepogodiev, Bhangu and glasbey22}

COVID-19 infections in the post-operative period of congenital cardiac surgery is poorly documented in the literature. ^{Reference Ogunjimi, Haiduc and Harky23} In the Global Multi-Societal Consortium, which analysed the pandemic’s initial impact on several Pediatric and Congenital Heart Surgery in 176 centres in 52 countries on 6 continents, infection in the post-operative period was reported in only 3 centres. ^{Reference Protopapas, Rito and Vida12}

With increasingly safer protocols and guidelines (pre- and post-operative), surgical outcomes for CHD can be nearly close to those of the pre-COVID-19 era, as demonstrated in some centres. ^{Reference Sabatino, Ferrero and Chessa24}

Pediatric and Congenital Heart Surgery will face the challenge of dealing with late referrals and patients with cancelled and postponed surgeries. New studies will be welcome to demonstrate the real impact on morbidity and mortality among CHD patients with delayed surgical repair.

In conclusion, the COVID-19 pandemic impacted the Brazilian Pediatric and Congenital Heart Surgery programmes with a significant decrease in surgical volume, increased complexity of surgical cases, and, consequently, increased mortality. Post-operative COVID-19 infection occurred in 48 cases, and mortality in infected patients in the post-operative period was much higher than in infected children in other conditions.

The most significant take-home message is that post-operative contamination may add significant risk. Pre-operative testing all surgical cases are of paramount importance, and separate flows in hospitals with COVID-19 patients are mandatory.