Virtual care has historically faced barriers to widespread adoption. However, the COVID-19 pandemic has necessitated the rapid adoption and expansion of virtual care technologies. Although the intense and prolonged nature of the COVID-19 pandemic has renewed interest in health systems resilience, including how services adapt or transform in response to shocks, evidence documenting the role of virtual care technologies in health systems resilience is scarce. At Toronto General Hospital in

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... , Canada, the rapid virtualization of cardiac care began on March 9, 2020 as a response to the pandemic. The objective of this study was to understand the experiences, barriers, and facilitators of the rapid virtualization and expansion of cardiac care due to the pandemic. A single-case study was conducted with three embedded units of analysis. Patients, clinicians, and staff were recruited purposively from an existing mobile phone-based telemonitoring program at a Heart Function Clinic in Toronto, Canada. Individual semi-structured phone interviews were conducted by two researchers and transcribed verbatim. An inductive thematic analysis at the semantic level was used to analyze transcripts and develop themes. A total of 29 participants were interviewed, spanning patients (n=16), clinicians (n=9), and staff (n=4). Five themes were identified: (1) patient safety as a catalyst for virtual care adoption; (2) piecemeal virtual care solutions; (3) confronting new roles and workloads; (4) missing pieces to virtual care; and (5) the inequity paradox. A motivation to protect patient safety and a piecemeal approach to virtual care adoption facilitated absorptive and adaptive resilience of cardiac care during COVID-19, while ad hoc changes to clinic roles and workflows, challenges building relationships virtually, and widened inequities were barriers threatening virtual care sustainment. We contend that sustaining virtual care hinges upon transformative, rather than adaptive actions, to strengthen health systems to face the dynamic and emergent challenges associated with COVID-19 and other shocks. Based on the barriers and facilitators identified, we present lessons learned and recommended transformations to sustain virtual care during and beyond COVID-19.