Structural heart disease monitoring critical during COVID-19 pandemic
As elective surgeries have been postponed due to the COVID-19 pandemic, it is important to monitor patients with structural heart disease via telemedicine and to know when an elective procedure becomes an emergent one, according to two documents.
The topic was addressed in a paper published in the Journal of the American College of Cardiology and in a consensus statement from the ACC and the Society for Cardiovascular Angiography and Interventions published in JACC: Cardiovascular Interventions.
Experience at NewYork-Presbyterian Hospital
Christine J. Chung, MD, interventional cardiology fellow at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, and colleagues described early experiences at their center that may be useful for other centers currently changing their practice to prepare for COVID-19 surges.
“Whether it’s in New York or in other areas, there are significant changes in how practice can be conducted,” Susheel K. Kodali, MD, director of the Structural Heart and Valve Center at NewYork-Presbyterian/Columbia University Medical Center, told Healio. “New York is one example of an extreme, but it goes along the spectrum from here to our friends in California, Washington and Chicago. Anticipation of the pandemic had to restructure how the service is functioning. We had to make judgements about what’s appropriate to do and what’s not.”
The recommendations focused on minimizing the risk for COVID-19 exposure to health care workers and patients; ensuring appropriate, timely and sensitive treatment of patients with structural heart disease; and limiting the utilization of resources when necessary.
Telemedicine can help minimize the risk for exposure to COVID-19 while preserving limited resources including ventilators, ICU beds and anesthesia care.
“I can’t comment for other regions, but in New York, what we’re seeing is that people are taking well to [the telehealth approach] because everyone is scared,” Kodali said in an interview. “What you see in the news and locally, everyone is just scared of being in the hospital. No one wants to come into the hospital. We’ve had patients that have heart failure that we’ve told, ‘We should probably move forward,’ and they say, ‘No, I’m OK.’ They’re terrified of COVID-19. It may be different in other regions, but here, we’re seeing that.”
Patients with scheduled visits to the valve clinic were contacted to keep their original appointment but as a telemedicine encounter or to postpone it to a future date when it is safer to conduct an in-person visit. Video encounters are often preferred because they allow subjective assessments of dyspnea, frailty and a limited evaluation of volume status. The camera can be aimed toward a patient’s legs to assess the severity of peripheral edema. If attempts for a video encounter fails, a phone call can be made to assess some aspects of a patient’s condition.
“As the vast majority of patient-physician interactions during the COVID-19 pandemic will transition to a remote interface, clear communication is critical to ensure that patients continue to receive high-quality cardiac care,” Chung and colleagues wrote. “Patients must be given specific instructions on how to self-monitor symptoms at home and when to call the clinic or consider an emergency department evaluation.”
Any scheduled intervention that may not affect clinical care or outcomes during the next 2 to 3 months is recommended to be considered elective and be postponed, which includes interventions for tricuspid regurgitation, closure of patent foramen ovales and atrial septal defects, and left atrial appendage occlusion.
However, procedures in patients with the threat of irreversible clinical consequences, imminent risk for mortality or the likelihood of rapidly worsening symptoms should be considered urgent or emergent based on the severity of risk. Some examples of emergent cases include severe mitral regurgitation with refractory HF and severe aortic stenosis with cardiogenic shock, whereas urgent cases would be in patients that cannot be discharged from the hospital without a procedure.
Cardiologists can triage their patients based on information from a previous telemedicine evaluation or heart valve clinic based as the following:
- emergent/urgent (tier 1): the highest risk cases that require a procedure within days or 1 to 2 weeks;
- semi-urgent (tier 2): patients at high risk for clinical deterioration over the next 1 to 2 months who require weekly intervals of close monitoring and an intervention within 1 to 2 months; or
- elective (tier 3): patients with a lower risk for deterioration if the procedure is postponed for at least 2 months.
“These tiers are not intended to be all-encompassing, but rather to provide illustrative case examples and general considerations to guide programs in prioritizing their own allocation of outpatient resources such as time spent by staff communicating with patients,” Chung and colleagues wrote.
All procedures scheduled for the next 2 months were rescheduled, and these patients receive a follow-up call every 1 to 2 weeks to see whether they are still stable before scheduling future check-ins. Surgical procedures such as valve repair and replacement should also be avoided during this time, according to the paper.
If it is determined that a structural procedure should proceed, any preprocedural testing should be streamlined to minimize interactions with health care professionals. For example, echocardiograms within the past 6 months can be used, and coronary angiograms can be performed at the time of the intervention if necessary.
If transcatheter aortic valve replacement is performed, a modified minimalist approach should be used including avoidance of transesophageal echocardiography, conscious sedation and plans to minimize length of stay.
These approaches should remain until a vaccine becomes widely available, even when the severity of the pandemic begins to lessen. Even as the number of cases of COVID-19 lessens, the burden on health care will change to one of accommodating the backlog of elective patients who require procedures, according to the paper.
“Resource allocation is important, and how we allocate the limited resources we have is very important,” Kodali told Healio. “You have to look at that based on the phase of the pandemic in the local areas. ... If you have enough resources that you’re not overwhelmed by the pandemic, you could consider doing cases, but even in that scenario, you have to weigh the risk-benefit of doing that case. Even if you have the ICU resources, if you have a minimally symptomatic patient, does it make sense to expose them to the risk of infection during the height of the pandemic? We would argue probably not.”
ACC/SCAI consensus statement
In a consensus statement published in JACC: Cardiovascular Interventions, Pinak B. Shah, MD, director of the cardiac catheterization lab at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, and colleagues focused on patients with structural heart disease who require intervention.
“Patients who are in need of structural heart disease intervention constitute a particularly challenging group, as many of them have conditions that may be life-threatening if intervention is inappropriately delayed,” Shah and colleagues wrote. “Therefore, decisions regarding timing of structural heart disease interventions must consider the risk of delaying the procedure, the risk for the patient of COVID-19 exposure outside of home shelter and utilization of limited hospital resources.”
Patients with severe symptomatic aortic stenosis are at increased risk for complications and death related to COVID-19 due to their advanced age and comorbidities. These patients are also at high risk for mortality if their treatment is delayed for months or years rather than weeks, according to the document.
TAVR should be considered for inpatients with severe symptomatic aortic stenosis linked to an ejection fraction reduction that is secondary to aortic stenosis, in addition to congestive HF or syncope. Urgent TAVR or close virtual monitoring can be considered for patients with NYHA class I to II HF symptoms and a critically tight valve. Patients who are asymptomatic may have their TAVR procedure postponed for 3 months or until hospitals resume elective procedures along with telehealth monitoring.
This consensus document also recommends a minimalist approach for TAVR procedures with moderate conscious sedation. PCI can be performed before TAVR if CAD contributes to a patient’s clinical presentation. Otherwise, PCI can be deferred until a later time.
Other procedures that can be safety deferred include percutaneous mitral valve repair, transcatheter mitral valve-in-valve replacement, transcatheter mitral valve-in-ring, paravalvular leak closure and valve-in-mitral annual calcification depending on a patient’s presentation.
The consensus document emphases the importance of minimizing multiple trips to the hospital for outpatient clinics through coordination of patient visits and utilization of telemedicine.
All clinical trials should be deferred until the COVID-19 pandemic is adequately resolved, according to the document.
“There remains significant uncertainty regarding the trajectory of the COVID-19 pandemic, but based on experience of other nations, the United States health care system must be prepared for a surge of critically ill patients in the coming weeks,” Shah and colleagues wrote. “A coordinated multidisciplinary effort needs to occur to safely defer and monitor structural heart disease patients requiring interventional therapies.”
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For more information:
Susheel K. Kodali, MD, can be reached at email@example.com.
Disclosures: Chung reports no relevant financial disclosures. Kodali reports he received institutional grants from Abbott, Edwards Lifesciences and Medtronic; consulting fees from Abbott, Admedus and Meril Lifesciences, and equity options from Biotrace Medical and Thubrikar Aortic Valve Inc. Shah reports he is a proctor for Edwards and received educational grants from Abbott, Edwards and Medtronic. Please see the publications for all other authors’ relevant financial disclosures.