Cardiology in the COVID-19 era: Performing TAVR in unprecedented times
The early days of the COVID-19 pandemic challenged interventional cardiologists in unexpected ways, including the disruption of all aspects of care and the halting of most transcatheter aortic valve replacements.
As cases rose in the spring of 2020, statewide mandates forced many hospitals to stop performing elective procedures. TAVR, which is primarily performed on an elective basis, was among them. Consequently, for several months, cath labs and operating rooms stood silent, except for urgent or emergent cases.
In an interview with Healio, Jordan G. Safirstein, MD, FACC, FSCAI, director of transradial intervention at Morristown Medical Center in New Jersey, discussed his personal experiences with COVID-19; how the disease affected care of patients with aortic stenosis and the decision to perform TAVR; what has changed within the past year; and a slow return to some degree of normalcy with the resumption of elective TAVR procedures.
Healio: What were the main challenges that interventional cardiologists faced early in the pandemic?
Safirstein: The first major challenge that comes to mind about the early TAVR experience during that time was the struggle — the limitations that the necessary COVID-19 precautions placed on sick cardiac patients before, during and even after the procedure.
Around April 2020, we knew COVID-19 existed, but we faced a lot of uncertainties, including a lack of treatment options for the disease. We were afraid and only just starting to learn more. We did not yet have rapid testing, which was a major hurdle, so we used full personal protective equipment for every case. This was concerning from a supply perspective in that we did not have powered air purifying respirators and were donning and doffing as best we could with the education that we had been provided. We were also reusing N95 masks because we were unsure about the provisions of them. In addition to supply concerns, the lack of rapid testing led to us using full PPE for every urgent or emergent case, which added another layer of difficulty to treating those patients. It takes time to achieve the appropriate level of protection, and we all know that certain situations, such as STEMIs, time is important. We felt that pressure to get moving and help the patient but also did not want to put our staff in harm’s way.
Further, we often would not have COVID-19 test results back for days at that time, so all our patients, no matter what, were still in isolation after receiving treatment. This often meant that they were not being examined on a regular basis by a physician or we were unable to do the same type of hands-on medicine that we would have done without the COVID-19 precautions in place. Basically, not only was the procedure itself a challenge, but the follow-up was difficult as well.
Healio: As the pandemic progressed, what were you seeing in terms of patients and their disease course?
Safirstein: Specific to our TAVR population, in the early part of the pandemic, we were not sure how long it would last. The TAVR population in general is often older and has multiple comorbidities, so our primary goal was to keep these patients safe. Therefore, if they were not in distress and were not actively symptomatic to the point where they would be hospitalized or seek medical attention, then we did not perform the procedure. In fact, there were at least a couple of months where we did not do a single elective TAVR case. Because these patients were stable, we did not want them to risk exposure and, similar to many institutions across the United States, we decided to halt all elective cases.
There were probably many patients who had already completed their workup and were ready to be treated with a valve replacement but just could not undergo the procedure because we stopped performing elective procedures. There was also another subset of patients who were probably in the middle of their workup, which would include a CT scan and other additional testing such as an echocardiogram or a dental exam. They also were not able to complete the process. Consequently, there were delays across the board for patients undergoing TAVR. However, there were obviously some patients who could not wait and they underwent TAVR at the hospital with the appropriate COVID-19 protocols in place. There was a significant amount of time where the necessary testing to get a patient safely to and through TAVR was totally stopped and elective TAVRs were also stopped.
Healio: What were some of your personal experiences during those early days?
Safirstein: It was a strange and wild time because New York and New Jersey were hit so hard. I actually contracted COVID-19 in April 2020, and when I returned to my office and the hospital after 14 days without symptoms, there was very little cardiology-related work for me. Instead, I just started working in the COVID-19 critical care floors, helping our awesome critical care team in any way I could. I would round where they told me to round and help by being the doctor on the floor for a little bit. I don’t really feel as though I contributed that much to the effort other than the fact that they just needed a doctor to call families or do other tasks.
STEMI calls were the only action going on in the whole cardiology realm. There were no echocardiograms, no elective testing, no elective procedures, no surgeries and even no cardiac clearances being performed. We also stopped seeing patients in the offices for a while.
I don’t remember exactly when we resumed elective cases again in the hospital, but it coincided with the ability to perform testing again. Once patients could be seen by dentists, have echocardiograms, CT scans and whatever else they needed to complete their workups, then we could resume performing elective TAVR cases. However, everything became a little more difficult and drawn out because we really had to overcome logistical challenges to get back to doing elective testing. It was harder to organize multiple tests and we could not completely control risks. You can tell your patient to quarantine, but can you guarantee that their son or daughter, who may be an essential worker and is bringing them to the hospital, always wears a mask when necessary? When cases were still rising, it was scary. Sometimes, you asked yourself, “Is this safe? Are we doing the right thing for patients?” But at least at my institution, we moved in a really methodical way. We did interact with what was going on statewide and we listened to the guidance from the CDC and our hospital administration. I feel like we have been able to create a good algorithm for our patients and operate in a really safe way.
Healio: How has the fact that TAVR is largely performed on an elective basis complicated treatment of aortic stenosis during the COVID-19 pandemic?
Safirstein: It is elective for the most part, but there are patients who are more actively symptomatic. If someone was admitted to the hospital with HF exacerbation, for example, then you might take a pause and consider the fact that that patient may need to be treated sooner than someone who is feeling well at home and is well compensated with no HF exacerbations. You can try your best to risk stratify using certain metrics like echocardiography-based criteria, which can help to identify patients who may need to be treated sooner, but TAVR is still an elective procedure and we do not do emergent TAVRs often. During the worst part of the pandemic, we held off on treating these less serious patients until we could get a grasp on what a reasonable protocol would be before bringing them to the hospital.
Healio: Has delayed intervention led to worse outcomes in patients with aortic stenosis?
Safirstein: There are studies that show that long delays in intervention can result in worse outcomes, such as a small increased risk for sudden cardiac death in patients with symptomatic aortic stenosis. We also know that patients with symptomatic aortic stenosis have a difficult course if not treated, but the length of delay is probably the key factor. Generally, development of aortic stenosis is a long, slow process, with most of our patients coming in and beginning their workup after their cardiologist has diagnosed them with severe aortic stenosis. Sometimes they have profound symptoms, but more often than not, they are usually in the beginning of their symptomatic journey.
In my own experience, I did not see significant decline in outcomes in our patient population. I believe we did a good job of trying to risk stratify our patients and treating those who needed to be treated. But I also do not think the delay in treatment was long enough to result in worse outcomes. Perhaps had the delay been significantly longer, then we would have worse outcomes in this patient population. However, this is just my experience.
Healio: How does the American College of Cardiology/Society for Cardiovascular Angiography and Interventions position statement recommend clinicians approach management of patients requiring TAVR during the COVID-19 pandemic?
Safirstein: The document is flexible with practical guidelines that can be tailored to a clinician’s individual situation. Overall, it emphasizes that circumstances change depending on the urgency of the procedure as well as the location of one’s institution, as each region of the country faced different challenges at different timepoints since the beginning of the pandemic. In general, it was important to be in touch with local case counts, trends and recommendations as well as state-based decisions because they dictated what could and could not be done at the time.
The document also touched on basic protocol that has become commonplace in the COVID-19 era, such as use of PPE and minimizing exposure by limiting a patient’s interactions with other patients and staff.
Healio: The ACC/SCAI position statement was published in June 2020. How do you think circumstances have changed since then?
Safirstein: A lot has changed, especially our management of COVID-19. Having lived with it for a year now, we are living with it much more comfortably. For instance, mask-wearing has become the norm and reliable outpatient testing has made a huge impact in how we can schedule cases. Also, we have much better patient awareness, so it is easier for them to understand the precautions that we take.
Moreover, now that people have lived with COVID-19 for a long time, they may not be as scared to come into the office or hospital because we can make them feel safe with the measures that we take and, to some degree, the populace is better educated about COVID-19 and how to handle themselves. We also have a system in place that has been running for essentially the last 9 months, so everything runs more smoothly and our staff operates more comfortably than we did at the beginning of the pandemic. We also have rapid testing now, so familiarity with the disease is probably the best advantage and our volume of cases is almost back to normal. So, a lot has changed, and for the better.
Healio: How did the pandemic impact how the heart team works?
Safirstein: All our meetings have moved to Zoom, and honestly, I don’t want to go back to the normal way. It’s so nice that everybody is now so facile with teleconferencing. Life can be much less stressful when you don’t have to show up in person for every meeting. We can be in our offices or at home, if that’s where we happen to be, but still attend the meeting and see slides, share data and interact. It took a few months for people to become comfortable with it, but now that we’re there, I’m not sure I want to go back to automatic in-person meetings. It should at least always be an option.
Regarding the heart team approach, we can now do these meetings in places where we maybe had not been doing them before because people were in different locations, such as different campuses. Telemeetings can be a very effective way of communicating and fostering a genuine team decision because everyone can participate.
Healio: Looking back over the past year, what have we learned?
Safirstein: We’ve learned that we can be adaptable and, as I mentioned, we don’t necessarily have to meet in person to be together. We’ve also learned that we never know what is going to happen in the years or even months to come. I do not think anybody could have predicted that COVID-19 would have become a global epidemic back when the virus first surfaced.
Additionally, from a personal standpoint, I learned how important it is to spend time with family, especially when given how threatening the world can be.
Finally, we should all recognize that nurses are heroes and that our hospital staff is amazing. The pandemic has shown that people, when thrust into terrible situations, really rise to the occasion, and respond most of the time. I never once saw anyone refuse to enter a room with a patient with COVID-19 or say they were not going to use PPE. Residents and interns did not shy away, and our cardiology fellows turned into COVID-19 doctors. Everyone is so brave. I learned that people who go into medicine for the most part truly want to help people, and during the pandemic, they really did. And they are owed a huge debt of gratitude.