Feature

Cath lab concerns prompted by COVID-19

Srihari S. Naidu

As more is learned about the COVID-19 pandemic, cardiology societies have issued advisories with steps to take in the cardiac catheterization laboratory to ensure optimal safety of patients and hospital personnel.

On March 17, the American College of Cardiology’s Interventional Council and the Society for Cardiovascular Angiography and Interventions issued a statement in the Journal of the American College of Cardiology with initial recommendations, notably stating that deferring elective procedures is prudent during the COVID-19 pandemic.

On March 25, a team of SCAI’s Emerging Leader Mentorship members and graduates issued an update with more specific recommendations, published in Catheterization and Cardiovascular Interventions.

“Now that we are about a week into the pandemic, we have a lot more information about what’s happening. We have read up a lot more on these things and we have some personal experience,” Srihari S. Naidu, MD, FACC, FAHA, FSCAI, director of the cardiac catheterization laboratory and the Hypertrophic Cardiomyopathy Program at Westchester Medical Center, Valhalla, New York, and one of the authors of the new document, told Healio. “As we have instituted policies in our institutions, we have gone through some of the logistics, and this is a culmination of that, at least at this time point, which the other document didn’t really have.”

#
Tips for the cardiac catheterization laboratory during the COVID-19 pandemic.

Nonessential procedures discouraged

Both documents strongly discourage performance of nonessential procedures at this time.

“CMS announced that all elective surgeries, nonessential medical, surgical and dental procedures be delayed during the pandemic,” Naidu and colleagues wrote. “Deferral minimizes risk of exposure to COVID-19 for patients and staff, and maximizes availability of inpatient beds in anticipation of a surge in hospitalization required for COVID-19-infected patients.”

The new document lists the following groups as those that could be deferred from having a procedure in the cath lab:

  • patients with STEMI and severe pneumonia, who should get conservative treatment or fibrinolytic therapy;
  • low-risk patients with non-ST segment elevation ACS who can be stabilized with medical therapy;
  • patients with type 2 MI or myocardial injury related to sepsis or acute respiratory distress syndrome;
  • patients with troponin-positive myocarditis without cardiogenic shock; and
  • patients who are slated for elective procedures and whose conditions are not life-threatening.

COVID-19 and STEMI

Frederick G.P. Welt

In patients with STEMI, conservative care is not an option, so “the balance of staff exposure and patient benefit will need to be weighed carefully,” Frederick G.P. Welt, MD, MS, FACC, FSCAI, associate chief of cardiovascular medicine and director of the cath lab at University of Utah Health, and colleagues wrote in the ACC/SCAI document.

Both documents noted that, in China, fibrinolytic therapy is often being used in place of primary PCI, and that may be considered for relatively stable patients with STEMI and active COVID-19.

“Right now, in our document, we are recommending that a primary PCI approach should continue; however, we discuss that this will be modified potentially by the prevalence and the risk of exposure as that grows over time,” Naidu told Healio. “We leave a door open to discuss whether fibrinolytics or other therapies can be utilized in these patients, both depending on the prevalence of disease and the frequency with which these patients may come in without a proper screen for COVID-19 that might risk exposure. For low-risk STEMI patients as well as STEMI patients who have significant pneumonia from COVID-19, it is not unreasonable to proceed with fibrinolytic therapy.”

Both documents noted that if primary PCI must be performed, all personnel must have the proper personal protective equipment (PPE), including a gown, gloves, goggles or shields and a N95 mask. In addition, use of powered air purifying respirator (PAPR) systems may be appropriate, especially in patients who are vomiting or those requiring CPR and/or intubation.

“We spend a good deal of time talking about full PPE and how to do it,” Naidu said. “There’s a section on donning and doffing PPE the proper way, because nobody in this country knew that prior to this. We discuss the fact that most places don’t have a negative pressure room. The alternative is to bring in a high-efficiency particulate air (HEPA) filter, which is what my institution is doing. Some institutions fit their cath labs with HEPA filters and take all the disposable equipment out, so you don’t inadvertently contaminate that.”

Because cath labs are not designed for infection isolation, terminal cleaning must be performed after a procedure in a patient with suspected or confirmed COVID-19, according to the documents.

COVID-19 and non-STEMI

Unlike patients with STEMI, patients with non-STEMI can be tested to confirm COVID-19 before a decision on a procedure is made.

Any patient with non-STEMI who undergoes a procedure should be discharged as rapidly as possible, given the needs to make beds available and reduce potential exposure to COVID-19, and followed up via telehealth, according to the authors.

In certain patients with non-STEMI and known COVID-19, conservative therapy may be the most appropriate option, particularly for those with type 2 MI, the authors wrote, noting that there is acute cardiac injury, usually in the form of type 2 MI or myocarditis, in approximately 7% of patients with COVID-19.

“Efforts should be made to try to differentiate between these type 2 MIs vs. ‘primary’ acute coronary syndromes, with consideration of deferral of invasive management in the former, especially if the patient is hemodynamically stable,” Welt and colleagues wrote in the ACC/SCAI document.

Unstable patients with non-STEMI may be treated similarly to patients with STEMI, according to the authors.

Staffing issues

The new document addresses how hospitals can manage cath lab staffs to best keep health care professionals and patients safe. It may be best to minimize exposure of personnel who are aged at least 65 years or who have chronic cardiac or pulmonary conditions, diabetes or hypertension to patients with known or suspected COVID-19, Naidu and colleagues wrote.

It suggests two models. One, the clustering model, divides personnel into a team of one attending physician, one CV fellow and two or three nurses and CV technologists who stay together until someone requires quarantine, at which point the whole team stays out of the pool until quarantine is lifted. On Monday through Thursday, two teams work during the day and a third team is on call at night. On Friday through Sunday, one team is on call.

The other, the hospital/home model, has one attending interventional cardiologist on-site Monday through Thursday, with another at home as backup and other attendings available if needed. The primary and secondary attendings rotate each week. On Friday through Sunday, the normal on-call schedule is maintained. Nurses and technologists have a similar rotation.

“It will be impossible for attending physicians to completely halt exposure to patients and health care providers outside of the catheterization laboratory, so these models do not necessarily limit the possibility of an attending physician spreading the disease to other areas,” Naidu and colleagues wrote. “However, the models do increase the chances of the catheterization laboratory staying functional even as disease prevalence rises.”

All personnel should practice social distancing as much as possible, with in-person staff meetings converted to virtual ones, Naidu and colleagues wrote.

Additional recommendations

Additional recommendations include:

  • Patients with confirmed or suspected COVID-19 should be intubated before arrival in the cath lab.
  • Decisions related to airway management of patients with confirmed or suspected COVID-19 should be made in conjunction with members of the critical care, infectious disease and anesthesia teams.
  • To reduce risk related to transport, certain procedures may be considered for the bedside instead of the cath lab, including pulmonary artery catheter placement, pericardiocentesis and insertion of intra-aortic balloon pumps. The new document added transvenous pacemakers and extracorporeal membrane oxygenation to the list.
  • If possible, cath lab procedures on patients with known or suspected COVID-19 should be done near the end of the day so as to minimize delays caused by terminal cleaning.
  • If possible, it may be a good idea to restrict procedures on patients with known COVID-19 to a single lab.
  • For procedures on patients with known or suspected COVID-19, the patient should wear a surgical mask and all members of the cath lab should wear PPE. The shortage of masks and other protective equipment is justification for deferring elective procedures and limiting the number of people who scrub in.
  • The new document recommends that all nonessential personnel be excluded from the cath lab to the extent possible during the pandemic.

Getting the message out

Although some institutions have started adopting the recommendations, others, especially those in areas not yet overwhelmed by patients with COVID-19, have not, so societies will continue to issue recommendations related to the cath lab throughout the duration of the pandemic, Naidu told Healio.

“My institution was ahead of the curve and other places are behind the curve, and as it gets busy, they may have trouble putting these policies in place,” he said. “So I think the document is helpful, even in the epicenter of New York, where there is still no consistency. This definitely helps bring consistency and helps protect our doctors from being forced to do procedures that might put them or the patient at risk because, during these times, it might be safer to have a consensus on which procedures should be deferred and which should be performed. Probably every 2 weeks, we’re going to have another manuscript to publish, given the rapidly changing landscape and as experience is accrued.”

Naidu said future documents are expected to address a problem that is starting to emerge: What to do with patients with COVID-19 who appear to have STEMI but actually do not.

“Some places are saying 25% to 40% of STEMIs in COVID-19 patients are not STEMIs, they’re myocarditis or vasospasm that mimics STEMI, so giving lytics may not be the right thing either,” Naidu told Healio. “We may ultimately move to things like a CT angiography to rule out STEMI in the ER, and at the same time look at the lungs, because these patients may not have any coronary disease at all, and you don’t want to give them lytics; they may bleed into their lungs or brain, causing a worse problem overall.” – by Erik Swain

References:

Szerlip M, et al. Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28887.

Welt FGP, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.03.021.

For more information:

Srihari S. Naidu, MD, FACC, FAHA, FSCAI, can be reached at srihari.naidu@wmchealth.org; Twitter: @sriharinaidumd.

Disclosures: Naidu reports no relevant financial disclosures. Welt reports he serves as a site principal investigator for a trial sponsored by Medtronic and serves on an advisory board for Medtronic. Please see the documents for all other authors’ relevant financial disclosures.

Editor’s Note: This article was updated on March 25, 2020, with new content after the release of the second SCAI document. It was updated again on March 26, 2020 to reflect changes in information in the infographic after the release of the second SCAI document.

Srihari S. Naidu

As more is learned about the COVID-19 pandemic, cardiology societies have issued advisories with steps to take in the cardiac catheterization laboratory to ensure optimal safety of patients and hospital personnel.

On March 17, the American College of Cardiology’s Interventional Council and the Society for Cardiovascular Angiography and Interventions issued a statement in the Journal of the American College of Cardiology with initial recommendations, notably stating that deferring elective procedures is prudent during the COVID-19 pandemic.

On March 25, a team of SCAI’s Emerging Leader Mentorship members and graduates issued an update with more specific recommendations, published in Catheterization and Cardiovascular Interventions.

“Now that we are about a week into the pandemic, we have a lot more information about what’s happening. We have read up a lot more on these things and we have some personal experience,” Srihari S. Naidu, MD, FACC, FAHA, FSCAI, director of the cardiac catheterization laboratory and the Hypertrophic Cardiomyopathy Program at Westchester Medical Center, Valhalla, New York, and one of the authors of the new document, told Healio. “As we have instituted policies in our institutions, we have gone through some of the logistics, and this is a culmination of that, at least at this time point, which the other document didn’t really have.”

#
Tips for the cardiac catheterization laboratory during the COVID-19 pandemic.

Nonessential procedures discouraged

Both documents strongly discourage performance of nonessential procedures at this time.

“CMS announced that all elective surgeries, nonessential medical, surgical and dental procedures be delayed during the pandemic,” Naidu and colleagues wrote. “Deferral minimizes risk of exposure to COVID-19 for patients and staff, and maximizes availability of inpatient beds in anticipation of a surge in hospitalization required for COVID-19-infected patients.”

The new document lists the following groups as those that could be deferred from having a procedure in the cath lab:

  • patients with STEMI and severe pneumonia, who should get conservative treatment or fibrinolytic therapy;
  • low-risk patients with non-ST segment elevation ACS who can be stabilized with medical therapy;
  • patients with type 2 MI or myocardial injury related to sepsis or acute respiratory distress syndrome;
  • patients with troponin-positive myocarditis without cardiogenic shock; and
  • patients who are slated for elective procedures and whose conditions are not life-threatening.
PAGE BREAK

COVID-19 and STEMI

Frederick G.P. Welt

In patients with STEMI, conservative care is not an option, so “the balance of staff exposure and patient benefit will need to be weighed carefully,” Frederick G.P. Welt, MD, MS, FACC, FSCAI, associate chief of cardiovascular medicine and director of the cath lab at University of Utah Health, and colleagues wrote in the ACC/SCAI document.

Both documents noted that, in China, fibrinolytic therapy is often being used in place of primary PCI, and that may be considered for relatively stable patients with STEMI and active COVID-19.

“Right now, in our document, we are recommending that a primary PCI approach should continue; however, we discuss that this will be modified potentially by the prevalence and the risk of exposure as that grows over time,” Naidu told Healio. “We leave a door open to discuss whether fibrinolytics or other therapies can be utilized in these patients, both depending on the prevalence of disease and the frequency with which these patients may come in without a proper screen for COVID-19 that might risk exposure. For low-risk STEMI patients as well as STEMI patients who have significant pneumonia from COVID-19, it is not unreasonable to proceed with fibrinolytic therapy.”

Both documents noted that if primary PCI must be performed, all personnel must have the proper personal protective equipment (PPE), including a gown, gloves, goggles or shields and a N95 mask. In addition, use of powered air purifying respirator (PAPR) systems may be appropriate, especially in patients who are vomiting or those requiring CPR and/or intubation.

“We spend a good deal of time talking about full PPE and how to do it,” Naidu said. “There’s a section on donning and doffing PPE the proper way, because nobody in this country knew that prior to this. We discuss the fact that most places don’t have a negative pressure room. The alternative is to bring in a high-efficiency particulate air (HEPA) filter, which is what my institution is doing. Some institutions fit their cath labs with HEPA filters and take all the disposable equipment out, so you don’t inadvertently contaminate that.”

Because cath labs are not designed for infection isolation, terminal cleaning must be performed after a procedure in a patient with suspected or confirmed COVID-19, according to the documents.

PAGE BREAK

COVID-19 and non-STEMI

Unlike patients with STEMI, patients with non-STEMI can be tested to confirm COVID-19 before a decision on a procedure is made.

Any patient with non-STEMI who undergoes a procedure should be discharged as rapidly as possible, given the needs to make beds available and reduce potential exposure to COVID-19, and followed up via telehealth, according to the authors.

In certain patients with non-STEMI and known COVID-19, conservative therapy may be the most appropriate option, particularly for those with type 2 MI, the authors wrote, noting that there is acute cardiac injury, usually in the form of type 2 MI or myocarditis, in approximately 7% of patients with COVID-19.

“Efforts should be made to try to differentiate between these type 2 MIs vs. ‘primary’ acute coronary syndromes, with consideration of deferral of invasive management in the former, especially if the patient is hemodynamically stable,” Welt and colleagues wrote in the ACC/SCAI document.

Unstable patients with non-STEMI may be treated similarly to patients with STEMI, according to the authors.

Staffing issues

The new document addresses how hospitals can manage cath lab staffs to best keep health care professionals and patients safe. It may be best to minimize exposure of personnel who are aged at least 65 years or who have chronic cardiac or pulmonary conditions, diabetes or hypertension to patients with known or suspected COVID-19, Naidu and colleagues wrote.

It suggests two models. One, the clustering model, divides personnel into a team of one attending physician, one CV fellow and two or three nurses and CV technologists who stay together until someone requires quarantine, at which point the whole team stays out of the pool until quarantine is lifted. On Monday through Thursday, two teams work during the day and a third team is on call at night. On Friday through Sunday, one team is on call.

The other, the hospital/home model, has one attending interventional cardiologist on-site Monday through Thursday, with another at home as backup and other attendings available if needed. The primary and secondary attendings rotate each week. On Friday through Sunday, the normal on-call schedule is maintained. Nurses and technologists have a similar rotation.

“It will be impossible for attending physicians to completely halt exposure to patients and health care providers outside of the catheterization laboratory, so these models do not necessarily limit the possibility of an attending physician spreading the disease to other areas,” Naidu and colleagues wrote. “However, the models do increase the chances of the catheterization laboratory staying functional even as disease prevalence rises.”

All personnel should practice social distancing as much as possible, with in-person staff meetings converted to virtual ones, Naidu and colleagues wrote.

PAGE BREAK

Additional recommendations

Additional recommendations include:

  • Patients with confirmed or suspected COVID-19 should be intubated before arrival in the cath lab.
  • Decisions related to airway management of patients with confirmed or suspected COVID-19 should be made in conjunction with members of the critical care, infectious disease and anesthesia teams.
  • To reduce risk related to transport, certain procedures may be considered for the bedside instead of the cath lab, including pulmonary artery catheter placement, pericardiocentesis and insertion of intra-aortic balloon pumps. The new document added transvenous pacemakers and extracorporeal membrane oxygenation to the list.
  • If possible, cath lab procedures on patients with known or suspected COVID-19 should be done near the end of the day so as to minimize delays caused by terminal cleaning.
  • If possible, it may be a good idea to restrict procedures on patients with known COVID-19 to a single lab.
  • For procedures on patients with known or suspected COVID-19, the patient should wear a surgical mask and all members of the cath lab should wear PPE. The shortage of masks and other protective equipment is justification for deferring elective procedures and limiting the number of people who scrub in.
  • The new document recommends that all nonessential personnel be excluded from the cath lab to the extent possible during the pandemic.

Getting the message out

Although some institutions have started adopting the recommendations, others, especially those in areas not yet overwhelmed by patients with COVID-19, have not, so societies will continue to issue recommendations related to the cath lab throughout the duration of the pandemic, Naidu told Healio.

“My institution was ahead of the curve and other places are behind the curve, and as it gets busy, they may have trouble putting these policies in place,” he said. “So I think the document is helpful, even in the epicenter of New York, where there is still no consistency. This definitely helps bring consistency and helps protect our doctors from being forced to do procedures that might put them or the patient at risk because, during these times, it might be safer to have a consensus on which procedures should be deferred and which should be performed. Probably every 2 weeks, we’re going to have another manuscript to publish, given the rapidly changing landscape and as experience is accrued.”

Naidu said future documents are expected to address a problem that is starting to emerge: What to do with patients with COVID-19 who appear to have STEMI but actually do not.

PAGE BREAK

“Some places are saying 25% to 40% of STEMIs in COVID-19 patients are not STEMIs, they’re myocarditis or vasospasm that mimics STEMI, so giving lytics may not be the right thing either,” Naidu told Healio. “We may ultimately move to things like a CT angiography to rule out STEMI in the ER, and at the same time look at the lungs, because these patients may not have any coronary disease at all, and you don’t want to give them lytics; they may bleed into their lungs or brain, causing a worse problem overall.” – by Erik Swain

References:

Szerlip M, et al. Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28887.

Welt FGP, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.03.021.

For more information:

Srihari S. Naidu, MD, FACC, FAHA, FSCAI, can be reached at srihari.naidu@wmchealth.org; Twitter: @sriharinaidumd.

Disclosures: Naidu reports no relevant financial disclosures. Welt reports he serves as a site principal investigator for a trial sponsored by Medtronic and serves on an advisory board for Medtronic. Please see the documents for all other authors’ relevant financial disclosures.

Editor’s Note: This article was updated on March 25, 2020, with new content after the release of the second SCAI document. It was updated again on March 26, 2020 to reflect changes in information in the infographic after the release of the second SCAI document.

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