Background: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training. Methods: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. Results: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. Conclusions: We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.

OBJECTIVES The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery programme and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care and enable support for the hospital in terms of physical resources, providers and resident training. METHODS In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our programme, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS We recognize that individual programmes around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programmes to plan for the future.

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Balancing risk of delaying operations versus risk of in-hospital COVID transmission Disruption of trainees' education and surgical skills Significant drop in revenue Division Department Hospital Enterprise Attending/staff/resident redeployment Serving as ICU attendings, ICU fellows, mid-level providers, junior residents, SWAT team, perfusion, and support staff in EDs, medicine floors, step-down units and newly created COVID-19 ICUs Adequate training and expertise in newly created roles Maintaining adequate core staffing of divisional and departmental services Increased risk of contracting COVID-19 Family exposure to COVID-19 Mental and emotional well-being given increased levels of stress Division Department Hospital Enterprise Service and on-call staffing Making residents, attendings and staff available for redeployment to COVID-19 units Maintaining staffing levels to safely care for remaining patients without COVID-19 (floors and ICUs) Availability of adequate senior resident/fellow and attendings to cover emergent cardiothoracic cases, urgent procedures, heart/ lung transplantation, and organ procurement Division Department COVID-19, coronavirus disease 2019; ICU, intensive care unit; ORICU, operating room intensive care unit; PPE, personal protective equipment; SWAT, Surgical Access Workforce Team.

Ascending replacement, in which mildly dilated distal ascending aorta was left behind. CENTRAL MESSAGEAlthough hemiarch repair adds little incremental surgical risk, data do not support its necessity in preventing aneurysmal dilation of the aortic arch.See Commentary on page 44.

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