A call to action becomes practice: Cardiac and vascular surgery during the COVID-19 pandemic based on the Lombardy emergency guidelines

Hub&Spoke Study Investigators, G. Bonalumi, I. Giambuzzi, A. Barbone, C. Ranieri, L. Cavallotti, P. Trabattoni, M. Naliato, G. Polvani, L. Torracca, S. Pelenghi, F. Ragni, C.F. Russo, F. Guerra, S. Trimarchi, E. Civilini, F. Romani, R. Bellosta, S. Losa, M. RobertoF. Alamanni

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.

Original languageEnglish
Pages (from-to)319-327
Number of pages9
JournalEuropean Journal of Cardio-thoracic Surgery
Issue number2
Publication statusPublished - 2020


  • Cardiovascular surgery
  • Coronavirus disease 2019
  • Hub-and-spoke
  • hydroxychloroquine
  • lopinavir
  • ritonavir
  • acetylsalicylic acid
  • antibiotic agent
  • apixaban
  • buprenorphine
  • clopidogrel
  • enoxaparin
  • fluticasone
  • irbesartan
  • lopinavir plus ritonavir
  • prednisone
  • pregabalin
  • prostanoid
  • vilanterol
  • adult
  • aortic regurgitation
  • clinical assessment
  • convalescence
  • coronavirus disease 2019
  • disease severity
  • drug effect
  • emergency care
  • female
  • frailty
  • heart ejection fraction
  • heart surgery
  • heart ventricle enddiastolic pressure
  • human
  • major clinical study
  • male
  • morbidity
  • pandemic
  • practice guideline
  • priority journal
  • Review
  • vascular surgery
  • acute kidney failure
  • aged
  • anamnesis
  • aortic coarctation
  • aortic valve replacement
  • artery disease
  • artery occlusion
  • Article
  • ascending aortic aneurysm
  • atrial fibrillation
  • brain hemorrhage
  • cardiopulmonary bypass
  • chemoradiotherapy
  • clinical protocol
  • computed tomographic angiography
  • computer assisted tomography
  • continuous hemofiltration
  • controlled study
  • diabetes mellitus
  • dyspnea
  • echocardiography
  • emergency health service
  • emergency surgery
  • endocarditis
  • false aneurysm
  • fever
  • ground glass opacity
  • health care access
  • health service
  • heart failure
  • heart muscle ischemia
  • hospital admission
  • hypertension
  • leg ischemia
  • limb pain
  • lung disease
  • lung edema
  • lung embolism
  • lung lesion
  • medical history
  • middle aged
  • nose smear
  • paravalvular leak
  • patient coding
  • patient identification
  • patient referral
  • percutaneous transluminal angioplasty
  • pleura effusion
  • prostate cancer
  • respiratory tract disease
  • screening test
  • Severe acute respiratory syndrome coronavirus 2
  • thoracotomy
  • thorax pain
  • toe gangrene
  • tracheostomy
  • transesophageal echocardiography
  • very elderly
  • Betacoronavirus
  • Coronavirus infection
  • emergency
  • health care planning
  • health care policy
  • hospital department
  • infection control
  • intersectoral collaboration
  • Italy
  • laboratory technique
  • organization and management
  • procedures
  • thorax surgery
  • virus pneumonia
  • Clinical Laboratory Techniques
  • Coronavirus Infections
  • Emergencies
  • Health Care Reform
  • Health Priorities
  • Humans
  • Infection Control
  • Intersectoral Collaboration
  • Pandemics
  • Pneumonia, Viral
  • Surgery Department, Hospital
  • Thoracic Surgery
  • Thoracic Surgical Procedures


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