Evaluation of intraoperative and postoperative cardiac changes in elective surgical patients with a history of COVID-19: A retrospective study

Introduction: Covid-19 is a deadly disease that has spread globally, declared a global pandemic by the World Health Organization (WHO), and is associated with treatment-resistant pneumonia cases. Although Covid-19 mainly affects the respiratory system and results in respiratory symptoms, the cardiovascular system is also significantly affected by the disease. While it is known that Covid-19 can cause cardiac arrhythmias and ECG changes during acute infection, it is uncertain to what extent these sequelae recover in patients who have recovered from Covid-19. Our aim is to determine the effect of COVID-19 on arrhythmias and prolonged QT in patients who have recovered from COVID-19 and underwent general anesthesia during elective surgery in the operating room Materials and Methods: In our study, elective general surgery patients operated at the Anesthesiology and Reanimation Clinic of the Akdeniz University Faculty of Medicine Hospital between May 2022 and May 2023 were retrospectively examined. A total of 201 patients who received general anesthesia with ASA score 1-4 and were between the ages of 18-75 were included in the study. Patients with complete data were included while those under 18, over 75, and requiring emergency surgery were excluded from the research. Archive and information management system scans were performed for the patients. The preoperative information of the patients was collected from the anesthesia outpatient evaluation form, intraoperative data was recorded in the anesthesia evaluation form during the process, and postoperative values were obtained from the service follow-up form to analyze changes in heart rate, occurrence of hypotension or hypertension, heart rhythm, SpO2 values, and recorded ECG scans. The patients' demographic information, history of smoking and alcohol use, Covid-19 vaccination status, and any symptoms during or after the infection were also noted. Preoperative ECG evaluation, coexisting conditions, history of medication use that prolongs QT interval, SpO2 after a 6-minute walk test, and breath-holding test in the preoperative period, as well as data obtained from anesthesia evaluation form during the intraoperative period and the patients' 24-hour average heart rate, systolic and diastolic blood pressure, mean arterial pressure, SpO2 values, and PACU/service/YCU admission status in the postoperative period were documented. Results: When comparing the duration of COVID-19 prior to surgery and the presence of symptoms, fatigue symptoms were found to be highest between 4-6 months (p=0.0051), while sleep symptoms were highest between 10-12 months (p=0.0453), and there was a statistically significant difference between the groups. When the severity classification of COVID-19 previously experienced by patients was evaluated according to gender, no statistically significant difference was found (p=0.3261). According to the results of the correlation analysis performed on the Qtc durations of patients by operation time, there is a moderate positive correlation of 45.149% in terms of Qtc duration during intraoperative and postoperative periods (p<0.0001). There is also a moderate positive correlation of 36.793% and 38.429% between Qtc preoperative duration and Qtc duration during intraoperative and postoperative periods, respectively (p<0.0001). In addition, breath-holding has been found to have a weak negative correlation between Qtc preoperative and postoperative duration (p=0.0003; p=0.0010). In other words, as the duration of breath-holding decreases in the cases included in the study, an extension of Qtc duration is observed. There was a statistically significant difference between intraoperative ventricular extrasystoles and COVID-19 severity classification in female patients compared to male patients (p=0.0097). Postoperative complication data for the patients included in the study were evaluated for female and male patients; AF was observed in 3 cases for females and SVT was observed in 3 cases, while in males, AF was observed in 1 case and SVT was observed in 1 case, but it was not found to be statistically significant (p>0.05). Preop-, introp-, and postoperative Qtc durations were evaluated for female and male patients; both preoperative and intraoperative Qtc durations were found to be longer in females than in males, and the difference was statistically significant (p=0.0163; p=0.0233). The preoperative Qtc durations of male patients were divided into two groups, those above and below 440 ms, and additional disease data were evaluated; a significant difference was found between groups in terms of kidney disease and LVH (p<0.05). When comparing preoperative Qtc durations of male patients with smoking status data, a statistically significant difference was observed (p=0.0387). Qtc was found to be above 440 ms in 80% of patients who smoked. When comparing postoperative ECG findings of male patients with preoperative QTc intervals, statistically significant differences were found between groups in terms of sinus rhythm, atrial fibrillation, and left ventricular hypertrophy (p<0.05). The male patients' breath-holding test results were also compared with preoperative QTc intervals, and a statistically significant difference was found between groups (p=0.0097) The preoperative Qtc durations of female patients were divided into two groups, 460 ms or above and below, and additional disease data were evaluated. According to this, significant differences were found between groups in terms of hypertension and CVD (p<0.05). No significant differences were found between groups of female patients in terms of smoking status, ASA grades, COVID-19 severity, and breath-holding times in terms of preoperative Qtc durations (p>0.05). When comparing the EKG values of patients before, during, and after surgery, it was found that there was statistically significant difference between groups in terms of Qtc> 500 msec, Bradycardia<60 bpm, Tachycardia> 100 bpm, and Ventricular extrasystole. Qtc> 500 msec was seen most frequently intraoperatively (6.5%) (p=0.0017); Bradycardia<60 bpm, Tachycardia> 100 bpm, and Ventricular extrasystole were also most frequently seen intraoperatively (p<0.0001). When comparing the Qtc durations of patients, the longest Qtc duration was seen in the intraoperative group (463.2±26.23) and the difference between groups was statistically significant (p<0.0001). Conclusion: Due to the possibility of permanent cardiac damage in a large portion of COVID-19 infected patients who recover, our study aimed to identify cardiac changes in patients who underwent elective surgery after COVID-19 infection during the intraoperative and postoperative periods and determine risk factors through patient follow-up during these processes. We detected EKG findings related to preoperative QTc prolongation in both female and male patients. Additionally, we found that changes in troponin levels were associated with QTc prolongation, and demographic factors such as comorbidities, ASA levels, and smoking could cause QTc prolongation in this patient group. Based on our findings and the few studies available on this topic, given the increasing prevalence of COVID-19 recovery in the population, it is essential for anesthesiologists to be prepared for potential cardiac problems in these patients during elective surgery. They should thoroughly evaluate all preoperative data and plan the anesthetic method and agents accordingly.