Letter to the Editor Open Access
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Virol. Nov 25, 2021; 10(6): 326-328
Published online Nov 25, 2021. doi: 10.5501/wjv.v10.i6.326
Evaluation of an asymptomatic COVID-19 patient post-surgery with chest radiography: A surgeon’s dilemma
Gaurav Govil, Lavindra Tomar, Pawan Dhawan
Gaurav Govil, Lavindra Tomar, Pawan Dhawan, Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi 110092, India
ORCID number: Gaurav Govil (0000-0002-2960-4372); Lavindra Tomar (0000-0001-8025-2723); Pawan Dhawan (0000-0001-8308-8228).
Author contributions: Govil G performed the study conception and design, and manuscript writing and revision; Tomar L contributed to the conception and revision of the manuscript into its final form; Dhawan P performed manuscript revision; all authors read and approved the final manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gaurav Govil, MBBS, MS, Surgeon, Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, 108 A, I.P. Extension, Delhi 110092, India. gauravgovil@yahoo.co.in
Received: May 27, 2021
Peer-review started: May 27, 2021
First decision: July 31, 2021
Revised: August 12, 2021
Accepted: November 14, 2021
Article in press: November 14, 2021
Published online: November 25, 2021


Routine chest radiography is not a requirement in post-surgery cardiac bypass patients. However, the safety of abandoning routine chest radiographs in critically ill patients remains uncertain. Surgery in an asymptomatic coronavirus disease 2019 (COVID-19) patient presents additional challenges in postoperative management. Chest radiography remains a valuable tool for assessment of all patients, even a stable one. Management of surgical patients as an emergency in an asymptomatic COVID-19 case remains a surgeon’s dilemma.

Key Words: COVID-19, Cardiac surgery, Radiography, Critical care, Chest radiography, Intensive care, Postoperative

Core Tip: Spallanzani guidelines consider chest radiographs as a valuable tool for initial assessment and follow-up of coronavirus disease 2019 patients, even in stable asymptomatic patients. A high index of suspicion will reduce the risk of high fatal postoperative outcomes.


We enjoyed reading the recently published article by Omar et al[1] about their observation on the necessity of chest radiographs (CXRs) in postoperative cardiac bypass graft cases in coronavirus disease 2019 (COVID-19)-positive patients. Although their series of patients with favourable post-surgery outcomes was small, their courage and willingness to help in the hour of need with the required COVID-19 protocols was commendable.

We agree with most of the content of the article. However, we would like to put forth more insights on the use of CXRs when dealing with surgical patients, especially an asymptomatic COVID-19 patient.

Omar et al[1] rightly indicated that routine CXRs are not a requirement in post-surgery cardiac bypass patients. This aspect has been researched and concluded by other authors in larger study groups. Rao et al[2] recommended performing CXRs only when clinically indicated, according to their finding from a study of 300 adult cardiac surgical patients showing satisfactory recovery. The systematic review and meta-analysis by Ganapathy et al[3] concluded that a restrictive CXR strategy in the intensive care unit does not cause harm; however, they cautioned that the safety of abandoning routine CXRs in critically ill patients remains uncertain. Tolsma et al[4] studied 1102 patients and concluded that selective CXR was an effective and safe approach once clear indications are defined. Porter et al[5] studied thoracic surgery patients and concluded that routine postoperative CXR in immediate intensive care management and later after final chest tube removal had a limited impact on clinical care.

Barkhordari et al[6] studied 25 asymptomatic COVID-19 patients undergoing emergent or urgent cardiac surgery, of which 84% received a cardiac bypass graft. They concluded that the majority of the patients had comparable early postoperative respiratory outcomes to their matched cohort of pre-COVID-19 patients. However, an intensive care unit readmission fared extremely poorly. They emphasised a lung-protective strategy during anaesthesia by maintaining appropriate tidal volumes with adjustments of ventilatory parameters based on perioperative acid-base and hemodynamic analyses.

Omar et al[1] reported on three asymptomatic cases with a mild grade of COVID-19 infection. Surgeries during the COVID-19 pandemic represent significant challenges for the patient and health care workers. There is a need for close monitoring of evaluation parameters or alarm signs in immediate postoperative management. The CXR utility for initial assessment and follow-up of COVID-19 patients is a valuable tool, even in stable patients as highlighted by the Spallanzani guidelines[7]. In COVID-19 infection, chest computed tomography in the postoperative period also needs judicious consideration based on the clinical distress symptoms to alert the surgeon of the possibility of the progression of respiratory involvement. A high index of suspicion will reduce the risk of fatal outcomes[8]. Abate et al[9], in their systematic review and meta-analysis on 2947 patients, revealed that perioperative mortality was 29% amongst the patients posted for emergency surgery. They also analysed hypertension as one of the most common comorbidities and pulmonary complications as one of the most common perioperative complications among surgical patients.

The developing strategies for management of asymptomatic COVID-19 patients during emergency surgery remains a surgeon’s dilemma. An asymptomatic COVID-19 patient may deteriorate abruptly and collapse quickly. A surgeon should maintain focus on decreasing perioperative mortality, preventing transmission of infection to health care workers, avoiding undertreatment, and adopting a less risky approach by undertaking routine CXR evaluation for immediate postoperative management. Of note, dyspnoea may present with COVID-19 pneumonia as well as myocardial infarction or acute decompensated heart failure. The surgeon needs to adapt constantly to the challenges of evolving clinical presentations, developing virus mutations and changing transmissibility of the COVID-19 virus to ensure patient safety.


Provenance and peer review: Invited article; Externally peer reviewed.

Specialty type: Virology

Country/Territory of origin: India

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Watanabe A S-Editor: Fan JR L-Editor: A P-Editor: Fan JR

1.  Omar AS, Shoman B, Sudarsanan S, Shouman Y. Chest radiography requirements for patients with asymptomatic COVID-19 undergoing coronary artery bypass surgery: Three case reports. World J Virol. 2021;10:130-136.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
2.  Rao PS, Abid Q, Khan KJ, Meikle RJ, Natarajan KM, Morritt GN, Wallis J, Kendall SW. Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient. Eur J Cardiothorac Surg. 1997;12:724-729.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 18]  [Cited by in F6Publishing: 8]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
3.  Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012;16:R68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 54]  [Cited by in F6Publishing: 39]  [Article Influence: 5.4]  [Reference Citation Analysis (0)]
4.  Tolsma M, Rijpstra TA, Rosseel PM, Scohy TV, Bentala M, Mulder PG, van der Meer NJ. Defining indications for selective chest radiography in the first 24 hours after cardiac surgery. J Thorac Cardiovasc Surg. 2015;150:225-229.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 7]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
5.  Porter ED, Fay KA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Routine Chest X-Rays After Thoracic Surgery Are Unnecessary. J Surg Res. 2020;250:188-192.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 4]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
6.  Barkhordari K, Khajavi MR, Bagheri J, Nikkhah S, Shirzad M, Barkhordari S, Kharazmian K, Nosrati M. Early respiratory outcomes following cardiac surgery in patients with COVID-19. J Card Surg. 2020;35:2479-2485.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 10]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
7.  Nicastri E, Petrosillo N, Ascoli Bartoli T, Lepore L, Mondi A, Palmieri F, D'Offizi G, Marchioni L, Murachelli S, Ippolito G, Antinori A. National Institute for the Infectious Diseases "L. Spallanzani", IRCCS. Recommendations for COVID-19 clinical management. Infect Dis Rep. 2020;12:8543.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 96]  [Cited by in F6Publishing: 79]  [Article Influence: 48.0]  [Reference Citation Analysis (0)]
8.  Niknam J, Rong LQ. Asymptomatic patients with coronavirus disease and cardiac surgery: When should you operate? J Card Surg. 2020;35:2486-2488.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 4]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
9.  Abate SM, Mantefardo B, Basu B. Postoperative mortality among surgical patients with COVID-19: a systematic review and meta-analysis. Patient Saf Surg. 2020;14:37.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 10]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]