 Good afternoon, friends. We are facing unprecedented situation due to COVID-19 pandemic. Not only our country, the rest of the world, all over the situation is same. I do have a conversation with a lot of my friends who are in North America and Western Europe. Everyone is facing these challenges. Two of my close cardiac surgeons who are in New York City, both of them, since last two months, they haven't done any cardiac surgery. They are doing their duties in CCU, managing the COVID patient who are on ventilators. I had a conversation with one of the friends in Howard Medical Center and their observation is the same. In Germany, the cardiac surgery is down somewhere 30% of the original. Now, let's see that how in this pandemic, our cardiac patients are facing the issues and how much they are vulnerable because of these problems and how we cardiovascular experts, cardiologists and surgeons are going to render our services to our patients who are in our follow-up, some of them who are the new patients and the patients who suffered with COVID and developed cardiac problems. It's not moving. The screen is not... Yes. Now, as we know, that the fatality after COVID, infestation is somewhere in the range of 2% to 3% worldwide. More than 80% of the patients who infected with this virus, they have very mild symptoms in our country. There are a lot many asymptomatic patients roaming around. However, morbidity and mortality increases significantly with age, rising to around 8% among patients who are 70 to 79-year-old and around 15% in the patients who are more than 80 years of age. Case fatality rate for comorbid patients are higher than the average population. Patients who are suffering with the cancer and if they get COVID, mortality in the range of 5.6%. Patients who are hypertensive and then they get this virus infection, mortality in the range of 6%. Chronic respiratory disease patients had got the mortality in the range of 6.3%. Diabetic, they are also having high mortality in the range of 7.3. And of course, patients who are suffering with cardiovascular diseases and get viral infection, some mortality goes somewhere between 10 to 11%. Now, let's see the implication for patients with undergoing cardiovascular, you know, who are having underlying cardiovascular problems. How they are supposed to prevent themselves that they don't get infection? And if somehow they get infection, how quickly they can be treated and they can escape from dreaded complications. Now, we advise that patients should take a prophylactic major like social distancing, continue all prescribed medication, including ACE-inviter and ARVs. Now, these patients who are never followed need not visit us in the hospitals and our clinics. Instead, we have to provide them telecommunication so that we can avoid chance of getting intermingled with the COVID patients. Some of the patients who are injured and heart patients, they may get pneumococcal vaccine and influenza vaccine as advocated by ASCA and AHA guidelines. Early identification isolation of cardiovascular patients is really mandatory. Triaging and prioritize the treatment for COVID-19 patient according to underlying cardiovascular, diabetic, respiratory, renal, oncological or other comorbidities. Don't ignore acute myocardial infarction symptoms. Acute event like AMI can be under reported or undiagnosed due to prevailing bias towards diagnosis of COVID. Now, patients who have got cardiovascular problems and if they get complication of COVID infection and they go into the hypertension or shock, it's very important to manage fluid balance very judiciously. Now, what we are following in our institution, this is very important. And this is also important that patients who are cardiovascular patients, they also present with breathing difficulty, chest pain or asthenia, while these three things are also a symptoms of COVID patients. Sometimes a cardiovascular patients get infection of COVID virus. So there is a combination of these symptoms. It's very difficult to identify whether they have COVID or they are manifestation of cardiovascular problems. Now, therefore require a very tight multidisciplinary collaboration in order to assign any single patient to the correct diagnostic workup process as soon as possible. In others, since the hospital like ours, where we are multidisciplinary hospital, we get flu patients, we get patients with pneumonia, we get a patient with respiratory problem and there are heart patients. For us, this is very mandatory that we should have a multidisciplinary approach to any patients who comes with a fever, breathing difficulty, chest pain to identify whether those symptoms are pertaining to pre-existing cardiac problems or those are because of COVID. Now, issues of protocol is very important and explicit diagnostic algorithm for trying for suspected COVID-19 infection is important. Patients with possible or probable or confirmed COVID-19 infection should be tries as COVID-19 infection. Now, critically ill cardiovascular patients who has got like a straining or who has got a cardiac arrest out of hospital, they should be presumed as SARS-CoV-2 positive until proven otherwise. Accordingly, healthcare personnel should bear adequate PPE, particularly in the triage phase. COVID test must be sent as early as possible. Patient must quickly access medical or international treatment according to the current evidence-based guidelines recommendation. In other words, any patients who comes with staining or who suffered cardiac arrest outside the hospital and revived, now these are the patients where we cannot wait for COVID test reports. We have to consider them as a COVID patient and start treating as early as possible. For that, our healthcare workers who are going to involve in the treatment, doctors, nurses, paramedics, they should have adequate protection in form of bearing, adequate PPE, N95 masks, gloves, headgear, whatever is mandatory to prevent themselves from not getting infected. Now, in Manipal Hospital, we have developed protocol where any patients, any patient who comes to the hospital, they enter from a one gate where the medical personnel record their temperature. If temperature is normal, then the patient can proceed. If the temperature is more than normal, he has symptoms. Then those patients are referred to a flu clinic in flu clinics, their symptoms is being checked, history is being taken, and if there is suspected COVID-like symptoms, then they are referred to the ER room. In ER room, if it looks like a COVID patient, the nexer is being done, and accordingly, if it looks like more close to the COVID, then they are referred to the COVID hospital. Otherwise, those patients who are not very close to the COVID symptoms are sent to the hospital where we have got a designated area for medical and surgical patients. Now, if it is a medical patient, they go to one area, there is a single room for each patient, and if they are waiting surgery or any procedures, they go to our other room, and then the COVID test is being sent, and they are treated like a COVID till we don't get COVID reports. Once the COVID report is released, turn out to be negative, then the medical patients are being referred to the CCU, and the patient for procedures, they are going to respective ward. So this is a protocol which we are following, and I think this is one by which we could able to identify and shift some of the COVID patients to the COVID hospital. Now, there is a situation when a patient who is very serious and require immediate ventilation, if they are in our facility, then there is no other way, but we have to wait, taking all the precautions, considering that is a COVID patients, and then we have to keep in our designated SGU, considering a COVID patient with all precautions, we send a COVID test, and if turn out to be COVID, we have to keep, because a ventilated patient, we cannot shift to the COVID hospital. So this is a protocol which we are following, and I think this is appropriate. Now, the protocol for diagnosis, trial, isolation, and management of COVID-19 patients with cardiovascular complications, and our cardiovascular patients with COVID-19 should be developed in detail, and should be rehearsed, because most of the cardiovascular experts, they are not earlier dealing with these kind of situation, they are not well versed with donning and doping of the PPE, putting a 95 mask, gear, and taking all the precautions. There are instances that during doping, healthcare individuals, they get interested, because of the virus. So this, everything is very important, and there should be a proper protocol, and the infection control department of the hospital should be involved to train repeatedly, and rehearse to healthcare workers, including cardiologists and cardiac surgeons. Now, specific protocols should be developed for management of acute myocardial infarction in contrast with the COVID-19 outbreak, both for patients with and without COVID-19 diagnosis. Now, particular emphasis should be placed on acute PCI and CVG, including protocols to limit catheterization lab or OR personnel to minimum. Whenever internal functional procedure is being done, angiography or angioplasty, there should be very minimal manpower in the cath labs, same in operation theater. Predetermining requirement for enhanced personal protection that is PPE, assessing post-procedural sterilization is sufficient. Once the procedure is done, one must follow the sterilization protocol and shut down the facility for one hour before taking the other patients. Thrombolysis is preferred in acute cases after astute clinical assessment, and this is worldwide. If there is not much complication, and if there is no contraindication for thrombolytic therapy for acute myocardial infarction, thrombolysis is the first choice. In extreme circumstances, clinical leaders may need to assess the risk-benefit ratio of acute myocardial infarction intervention. Given a limited data on primary PCI benefits for type 2 MI from acute viral illness against no-jocoberefaction, it means that one has to bail that healthcare workers may get no-jocoberefaction as compared to the benefit of PCI in a patient with acute myocardial infarction. And accordingly, if there is no contraindication for thrombolytic therapy, I think that should be preferred. Now, what happens to the patients who are hypertensive, who are at home? They must continue taking their antihypertensive drugs. They can contact their doctor on telephone or on tele-consultation. They should monitor their blood pressure and try to inform the healthcare providers, their doctors, what are their status. Now, the patients who are admitted in the hospital with their hypertensive crisis, they should make a notice according to the protocol. They must continue ACE inhibitor ARVs unless high-potency or there is an acute kidney injury, continue treatment with antihypertensive medication according to the ESC and ESS guidelines after 2018. Some of these patients may develop cardiac arrhythmias. One must check their potassium level. Some of them may develop hypercalema because of that there may be arrhythmias. Parental antihypertensive medication will only rarely be necessary in ventilated patients. Now, let's see what are the acute cardiac complication of COVID-19 patients. There are now immense reports available from China, from Italy, from Spain and now from United States of America that there is incidence of acute onset heart failure, myocardial infarction, myocarditis and cardiac arrest in COVID patients. In a recent case report of 138 hospitalized COVID-19 patients, 17% of patients they develop arrhythmias and 7.2% experience acute cardiac injury. In addition to other COVID-19 related complication. So the cardiac team should be prepared to assist other clinical facilities in managing cardiac complication in severe cases of COVID-19. One must advise troponin BNP condition in high-risk cases. Patients demonstrating heart failure, arrhythmias, ECG changes or cardiomegaly should be advised with echocardiography. Critical care and cardiac teams should confer to guide care for patients who are requiring extracurricular circulation support with Dinovina sigmo versus Vinoarticle ECMO. There are reports from France that they have very good outcome from VV ECMO in a patient who are not able to manage with intubation and prone ventilation. But the same good VV ECMO results are not being duplicated in other part of the world. In China, they have very significant mortality. Around somewhere in 80% mortality of VV ECMO patients. So one has to see and if when to put a VV ECMO, one has to put VV ECMO in little advance not too late and already some complication has occurred. But one has to weigh when to intubate if one can try to avoid intubation and give even a prone position and give a bi-pare, par-c-pare is better than individual ventilation. Now after intubation, if patients could not able to sustain a PO2, then one can consider VV ECMO. Now, let's consider what is the emergent or urgent procedures which are really required in this COVID pandemic time or which are the elective or non-urgent procedures which can be postponed. Now, the pandemic can be divided into three stages. In stage one, the hospital works with reduction of around 0 to 30% work of routine cases. Now in that stage one, the essential services like all patients who are waiting in surgery, including emergency surgery, they should be given services. How patients who are greater risk of adverse event like symptomatic critical AS, symptomatic severe coronary ART disease with left-men disease, three-basal disease with low EF, cardiac tumors at the risk of obstruction or immolization, aortic aneurysm at the risk based on this very rapidly increased size and threatening ruptures are patients who require TABI for critical AS. These essential services should be rendered to our patients. Now, what are the procedures which can be deferred? All other patients who will mainly be least symptomatic outpatients, they should not be admitted and should not be given further treatment. Truly elective intervention could include asymptomatic severe MR, ASD and PFO surgery, asymptomatic aneurysm with a demonstration of a stable size which are not increasing. These patients can wait. But one must take precaution that patients should be informed the prevailing COVID situation and ask that they should inform if any emergency develops and if there is some acute catastrophe. Then those patients should be admitted and should be given appropriate treatment. Otherwise, patients can wait. Now, if the pandemic reach into the stage 2 where most of the hospital, they reduce their works from 30 to 50%, in that situation, the essential services like all inpatient waiting for surgery including emergency services, they should be given a treatment. Outpatient who are most symptomatic and demonstrated to fail medical management which are not respondent to medical treatment, they can be admitted and they should be given appropriate treatment. Patient who are waiting for Tavi and who require very short hospital stay, they should also be given Tavi and they can be discharged early. What are the procedure which can be different? All patients who will mainly be least symptomatic and outpatient, they should not be dealt with at this time, but these patients who are deferred from proper procedure, they should also be informed if they are in the waiting list and the date has been given to the prevailing situation and all of them, they should also contact the service provider if there is some complication, develops and symptoms become very bothersome. Now, if the pandemic reach in the stage 3 where more than 50% reduction in the hospital services, then only very essential services like only emergency services based on resource availability and most urgent in the patients who are already admitted, they should be treated. Now, what are the patients who are being deferred? All patients just to be stable and capable of waiting. All outpatients, they should not be admitted. Patient deteriorating while waiting need to meet criteria for admission before consideration for surgery or other target procedures. But again, these deferred patients or who are waiting for procedure should again be informed about prevailing situations and ask them to report to the healthcare provider once there is some catastrophic some emergency or exaggeration of the symptoms. Now, one can divide based on case-to-case basis like patient who are ischemic has got heart disease. Now, which is emergency, which is urgent, which is lower priority, which is elective cases and accordingly they have to take it. Same, bowel blood surgery, acute or chronic heart failure, patient who has got arrhythmia, heart block and other intervention, they should be categorized depending on the priority. Emergent, urgent, lower priorities and elective cases and accordingly they should be treated or given dates. Now, patient with a staining during COVID-19 pandemic, any patients who comes to your hospital with staining treat him like a patient of COVID with staining and accordingly you see that the patient can be a candidate for fibrolysis or primary PC. Now, the patients who are self-reported to particular hospital, if they turn out to be a COVID patient, they can be referred to the COVID hospital where they are eligible 24-7 cath labs so that they will manage there. If not, then they can be given fibrolytic therapy depending on their situation and if there is no other contraindication. Now, patient with non-ST segment elevated acute coronary syndrome, now their symptoms should be whether they are high risk, very high risk, intermediate risk and low risk depending on that. They should be treated that they need a PCI or they can be easily managed with a traumatic therapy or other collaborative treatments. Now, this is very important to that our healthcare workers should be prevented for getting infection. This is really, really important. Particularly when we getting the patients who are in the cardiac shock or who has a cardiac arrest out of the hospital. Now, these situation, these patients should be treated like a COVID patients and all the necessary precautions should be taken with full PPE and 95 mask, gloves, goggles and accordingly, these patients should be treated depending on their prevailing situation. Now, risk to the healthcare person. This is very important. This has been seen that a lot of healthcare workers they are getting tested because of their close proximity to the patients. So one must, there's a numerous report worldwide and also now some of the reports are emerging from our country itself that a lot of healthcare providers they are getting infected. And a lot of, I already narrated that maybe because of doping when they are taking out their personal protective equipment, they get interested. So one has to be very, very careful. This is a responsibility of administrator, infection control team to train the manpower very judiciously repeatedly so that they may not be getting tested because of doping because of close proximity. Now, if a healthcare worker, they get some symptoms which are already mentioned, cough, fever, shortness of breath, insomnia, muscle ache, they immediately should become tested from time to time, the test should be sent. And if they turn out to be COVID positive, they should be either shifted to the COVID hospital or if there is a provision to keep them in the same hospital, they should be treated accordingly. And their contacts should be traced and they should also go on time. Now, various protective gears which a doctor should need, healthcare worker should need, it depends on the kind of procedure they have to perform. So this can be divided into level one which is like an outdoor procedure, what they have to wear, the kayak, the mask. Now, if they are going for investigative room, then they have to put specific which are being shown here or if they are going for aerosol generating procedures or in the operating room, they should be given a proper N95 mask, PPFP3 mask or headgear and whatever is required. So this one has to categorize because available resources, the kind of procedures and the involvement of healthcare worker to particular procedures. And accordingly, one must categorize and this is our administrator to make sure that required gears are available to healthcare workers. Now, these are some of the masks. One can have PP3 where even 0.023 micron particle cannot cross. Then there is N95, then there is a powered air purifier respirator. Now the problem is that this is really cumbersome to wear and particularly for us surgeons, it's very difficult to wear and perform surgery because as a cardiac surgeon, we need a loop and this is difficult when we are putting these headgears. Now, donating, as I mentioned, this is very important and there should be continuous rehearsal and alert should be given to the healthcare worker how to put these protective gadgets. Same is for doping, one has to be very, very careful. Then for the cardiac surgeon, we have got a recommendation from Society of Thoracic Surgeons which has given that when any patients comes for any procedure, they should be sent a test and we try to perform the procedure within 48 hours of getting the test report because if these patients will wait for more, then there may be infection during the waiting period. So this is very important. Another thing is that try to avoid any emergency in half hours because the availability of manpower and everything is important. Now, when you are performing aerosol generating procedure, one has to be careful, try to avoid aerosol generating procedures like endowain harvesting and endoscopic surgery. And most important, there should be minimal manpower present into the operation theater or cathlet so that they may not get infected. We should have a bare minimum. Now prevention is very important. Interaction with other or avoid people who are sick, keep at least two meter distance which is general precautions, wash hand thoroughly with soap and warm water, at least for 20 seconds, cover the mouth or nose when you cuff or sneeze with tissue or use inside of your elbow, avoid touching the eyes, nose, mouth to remove the virus often clean surfaces like doorknobs or handles with disinfectant, self isolate in case of symptoms of fever, cough or chest infection, stay home as much as possible and maintain physical activities. Now, healthy lifestyle is important. Do some yoga, quit smoking if you are minimally healthy, eat healthy, all these things are really important. At this juncture, we healthcare workers, doctors, nurses are in a very, very unprecedented situation. We get a lot of news which are bad news. We get depressed so one has to encourage each other, try to talk in telephone to your relatives, friends, watch some good movies, read some good books so that you can get motivated. Very important that you must get enough sleep that is very, very important. And I know a lot of my friends, they use melatonin in the US because at least six to eight hour sleep is very, very important, eat healthy. And if there is some symptoms, try to report as early as possible so that you can prevent others to get interested and yourself may get appropriate treatment before getting complications. Now, patient information is very important and we are doing that as healthcare worker. So in that sense, this is our responsibility at this juncture as a cardiovascular expert to take care of our patients who are already suffering with cardiovascular problems. And if by any chance, those patients get infested because of the virus, they are supposed to be given appropriate treatment. The COVID hospitals, if they are getting admitted to patients, those patients may develop a complication which are related to cardiovascular existing problems or they know about because of the virus and those should be also managed. Thank you. Thank you for patients listening. If there is any questions, please try to put me, I will be able to answer those. Yeah, because so some of the medications which are being used for COVID patients, particularly hydroxychlorophenes and tetromycin, these are the two medication which are really having some effect on the heart. And the most important is the QT prolongation with hydroxychlorophenes. So the patients who are a COVID patients and if they develop complications of the cardiac complications, someone has to be very careful before giving these medications. One has to see the ECG and see the QT. And if I know some of the patients whom the hydroxychloroquine started and they have to stop because there was a QT prolongation. There are some deaths also reported in our country. We know one of the cardiac anesthetists. He took hydroxychloroquine as a preventive measure and he has to succumb because of the complication. So there are some arrhythmia and there are QT prolongation. So one has to be very careful. There are some of the antiviral may have some bearing on the heart. So one should be very, very careful whenever you are using these particularly the hydroxychloroquine from ICU. Now another question is what is the guidelines for primary PCI in a stable patient in this scenario? Now our hospital protocol is that whenever a patient comes with acute myocardial infarction, if he's stable, then we try to send the test. And if test comes negative, then our cardiologist take and try to, if there is some contraindication for fibrolysis, then they take for PCI. Now if a patient is unstable with acute myocardial infarction, then there is no other way. Treat as a COVID patient with acute MI and take into the cath lab with all the precautions with PPE on, with all the healthcare workers and do the needful. But the worldwide, now the preference is far from politic currently. First of all, if their response is fine, if they not, then there is no other way but to take for PCI. Yeah, why COVID patient has higher incidence of myocardial infarction and related complication? Now there is another question of why the COVID patient has a high incidence of myocardial infarction and related complication. Now this has been seen that the virus, there are two impact. One is the direct impact. The virus can go into the myocardium and produce myocarditis. So this is a direct impact. Another impact is secondary because of the involvement of pulmonary circulation and because there is a diffuse thrombosis of the arterial system. So the coronary arteries, they also get thrombosed and then there is a myocardial infarction. So there are two things. One is the direct involvement of the myocardium leading to the myocarditis. And second is diffuse clot formation in the vasculature, which leads to myocardial infarction. So these are the two things responsible for myocardial infarction and related symptoms in COVID-19 patients.