Many Transcatheter Valve Interventions Can Wait Until After COVID-19 Pandemic: Societies

By Will Boggs MD

April 21, 2020

NEW YORK (Reuters Health) - Most transcatheter mitral-valve repairs (TMVRs) and many transcatheter aortic-valve replacements (TAVRs) can be delayed until the COVID-19 pandemic is over, according to a consensus statement from the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI).

"The decisions to perform structural-heart-disease intervention during this pandemic are going vary depending on the severity of the patient's valvular heart disease, the severity of the COVID-19 situation locally, and the availability of vital hospital resources," said Dr. Pinak B. Shah of Brigham and Women's Hospital, in Boston, and the ACC Interventional Cardiology Section Leadership Council, in Washington, D.C.

"For every case, a careful decision needs to made balancing the risk of delaying an important procedure vs. the risk of bringing a patient into a hospital environment where resources may be limited and the coronavirus may be more concentrated," he told Reuters Health by email.

The COVID-19 pandemic has complicated the effective triage of patients with valvular and structural heart disease, as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment versus the risk of delaying a needed procedure.

Writing in JACC: Cardiovascular Interventions, Dr. Shah and colleagues provide a framework for triaging these patients during the COVID-19 pandemic.

The main priorities, they say, are to minimize exposure to coronavirus for patients and the interventional team; maintain high-quality outcomes in patients who do require a procedure during the pandemic; reduce the risk that these patients use resources that might be needed for COVID-19 patients; and prevent delay of intervention in patients at high risk for clinical deterioration, heart failure and death.

The timing of TAVR for patients with aortic stenosis depends largely on the level of symptoms. TAVR should be considered for patients with severe to critical aortic stenosis and NYHA class III-IV congestive heart failure (CHF) symptoms.

Urgent TAVR or close outpatient virtual monitoring are reasonable alternatives for patients with NYHA class I-II symptoms and quantitative measures of valve severity that indicate a critically tight valve.

For truly asymptomatic patients, consideration of TAVR can be reasonably postponed for several months or until after hospital operations resume elective procedures.

Most percutaneous mitral-valve repairs can be safely deferred, according to the authors. Possible exceptions include the following: inpatients with severe functional mitral regurgitation (FMR) who cannot be safely discharged despite optimized guideline-directed medical therapy (GDMT); outpatients with severe FMR with recent hospitalization for CHF despite optimized GDMT; inpatients with CHF and severe degenerative mitral regurgitation (DMR) due to acute valvular dysfunction; outpatients with severe DMR with recent hospitalization despite GDMT; and inpatients with either severe FMR or DMR who are in low-output, decompensated heart failure requiring ICU-level care where TMVR might improve hemodynamics and allow extubation and/or transfer out of the ICU.

Transcatheter mitral valve-in-valve replacement should also be deferred until after the COVID-19 pandemic is over, so long as patients can be sufficiently managed on medical therapy in the interim.

Paravalvular leak closure, patent foramen ovale closure, atrial septal-defect closure, left atrial-appendage occlusion and alcohol septal ablation for hypertrophic cardiomyopathy should generally be deferred until after the moratorium on nonessential procedures has been removed.

In all cases, centers should establish a system that provides weekly virtual follow-up for patients whose procedures have been deferred. Interventional teams should convene at least weekly (and virtually, if necessary) to review the status of patients on the waiting list.

"It is important to note that these are general guidelines but in no way are meant to be formal rules, as we fully realize that the threshold to consider treatment for patients with structural heart disease will vary depending on the severity of the COVID-19 situation at a particular institution," Dr. Shah said.

"It may be easier to treat a patient with a procedure in a geographical area that is not yet overwhelmed with COVID-19, whereas that very same patient may not be able to be treated in an area with a higher incidence of the infection and fewer institutional resources to perform non-emergency procedures," he added.

SOURCE: JACC: Cardiovascular Interventions, online April 6, 2020.


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