Streamlined Aortic Stenosis Care During COVID-19

Debra L. Beck

June 17, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The COVID-19 pandemic has forced providers to focus on the really critical aspects of emergent care. As communities emerge from the worst days of the pandemic, the question is whether those minimalist approaches might be better than the more resource-heavy care provided before the pandemic.

In a Viewpoint article published online June 2 in JACC Cardiovascular Interventions, Sammy Elmariah, MD, MPH, Massachusetts General Hospital, Boston, Massachusetts, and colleagues consider the management of severe aortic stenosis (AS) during the COVID-19 era.

Initially designed as a means to limit patient exposure to COVID-19 and to preserve resources, Elmariah suggested in an interview that it might be appropriate to adopt at least some of these measures going forward, after the pandemic passes.

"I think the major take-home message is that we can streamline our practices," said Elmariah to theheart.org | Medscape Cardiology. "Having had to reevaluate how we do things in order to minimize interactions with these very sick patients during COVID, I think there are a number of lessons we can take forward that will improve efficiency and resource utilization."

Severe AS most commonly affects the patients most at risk for complications from COVID-19, namely, the elderly and those with cardiovascular comorbidities. To avoid unnecessary morbidity and mortality, prompt referral and evaluation of patients with severe disease are important.

Although all cases of symptomatic, severe AS are matters of urgency, Elmariah and colleagues propose a grading algorithm by which to judge the acuity of AS symptoms and gauge the urgency for addressing those symptoms.

"Certainly there were situations that arose during COVID-19 ― and we'll continue to see arise post COVID ― that demand that you prioritize patients, so I think our risk stratification scheme will carry some weight even beyond the current crisis and can help give us some sense of which patients we must treat urgently and which can potentially hold off for a little bit of time," said Elmariah.

The author said that patients with mild, stable symptoms can be assessed virtually every 1 to 3 months for disease progression; those with moderate but stable symptoms should be monitored virtually more often, perhaps every week or two.

Individuals with severe, unstable symptoms require in-person assessments and repeat transthoracic echocardiography to assess for new left ventricular dysfunction. For these patients, urgent aortic valve replacement is prudent despite risks related to COVID-19, say the authors.

Another suggestion Elmariah and colleagues make is to decide early on whether the patient might be best suited for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) and to customize subsequent testing and assessments accordingly.

"We do a number of different tests in these patients because we're essentially evaluating them concurrently for TAVR and SAVR. I think this can be streamlined, regardless of which approach you want to take, so that this decision is made earlier in the process and the evaluations can be trimmed and personalized for that specific patient," said Elmariah.

As an example, if TAVR is the preferred approach, coronary angiography can be performed at the time of the procedure rather than during the assessment period, as is routinely done.

In a similar way, the authors suggest rethinking the standard battery of tests usually conducted before SAVR. As an example, pulmonary function tests can be deferred for patients who do not have a history of smoking, and it can be performed only if severe pulmonary disease is suspected, said Elmariah.

Similarly, dental evaluations can be triaged on the basis of the presence of gross dental symptoms or pathology.

"Our concern is always the patient's well-being first and foremost, and in this situation, we really have to accept the fact that every time there's an in-person interaction, we are subjecting that patient to risk. So, every single element of everything we do has to be critically evaluated, and this is likely to remain the case for a good while yet," said Elmariah.

At this point, it's uncertain whether these changes will stick once the crisis is over, said Elmariah, but his group intends to study their minimalist approach to see the impact on outcomes, processes, and resource utilization.

"It's one of the things I continue to hear during this time is that we're learning how little you can get away with. The American medical system, in particular, is somewhat blessed in that we have access to a tremendous amount of resources, and in the routine care of patients, we use those resources, and we've not had to really consider limitations in those resources until now."

Elmariah has received research grants from the American Heart Association, the National Institutes of Health, Edwards Lifesciences, Svelte Medical, and Medtronic and has received consulting fees from AstraZeneca.

JACC Cardiovasc Interv. Published online June 2, 2020. Abstract

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