How to Reboot Elective CV Procedures After COVID-19 Lockdown

Megan Brooks

June 25, 2020

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

With the COVID-19 pandemic winding down in some parts of the United States, attention has turned to figuring out how to safely reboot elective cardiovascular (CV) services, which, for the most part, shut down in order to combat the virus and flatten the curve.

To aid in this effort, top cardiology societies have published a series of guidance documents.

One, entitled Multimodality Cardiovascular Imaging in the Midst of the COVID-19 Pandemic: Ramping Up Safely to a New Normal, was initiated by the editors of JACC Cardiovascular Imaging and was developed in collaboration with the ACC Cardiovascular Imaging Council.

"As we enter a deceleration or indolent phase of the disease and a return to a 'new normal' for the foreseeable future, cardiovascular imaging laboratories will adjust to a different workflow and safety precautions for patients and staff alike," write William Zoghbi, MD, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Texas, and colleagues.

Minimize Risk, Maximize Clinical Benefit

Writing in JACC: Cardiovascular Imaging, the group outlines strategies and considerations on how to safely ramp up multimodality CV imaging laboratories in an environment of an abating but continuing pandemic.

The authors provide detailed advice on reestablishing echocardiography, transthoracic echocardiography, transesophageal echocardiography, stress testing modalities, treadmill testing, nuclear cardiology, cardiac CT, and cardiac MRI.

The advice is designed to "minimize risk, reduce resource utilization and maximize clinical benefit," the authors say. They address patient and societal health; safety of healthcare professionals; choice of CV testing; and scheduling considerations.

Zoghbi and colleagues say integrated communication among patients, referring physicians, the imaging teams, and administrative staff are key to reestablishing a more normal clinical operation.

"Recognizing that practice patterns and policies vary depending on institution and locale, the recommendations are not meant to be restrictive but rather to serve as a general framework during the COVID-19 pandemic and its recovery phase," the writing group says.

Ultimately, the goal is to offer the necessary CV tests and information for the clinical team to provide the best care for patients, they add.

"To be successful in this new safety-driven modus operandi, innovation, coordination and adaptation among clinicians, staff and patients is necessary till herd immunity or control of COVID-19 is achieved," they conclude.

Rebooting Electrophysiology Services

Uncertainty as to how to resume electrophysiology (EP) services for arrhythmia patients prompted representatives from the Heart Rhythm Society (HRS), the American Heart Association (AHA), and the ACC to develop a series of "guiding suggestions and principles" to help safely reestablish electrophysiologic care.

The 28-page document is published in Circulation: Arrhythmia and Electrophysiology and the Journal of the American College of Cardiology Electrophysiology.

"Rebooting" EP services at many institutions may be more challenging than shutting down, write Dhanunjaya R. Lakkireddy, MD, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, and colleagues.

Topics addressed by the writing group include the role of viral screening and serologic testing; return-to-work considerations for exposed or infected healthcare workers; risk stratification and management strategies based on COVID-19 disease burden; institutional preparedness for resumption of elective procedures; patient preparation and communication; prioritization of procedures; and development of outpatient and periprocedural care pathways.

They suggest creating an EP COVID-19 "reboot team" made up of stakeholders involved in the EP care continuum pathway that would coordinate with institutional or hospital-level COVID-19 leadership.

The reboot team may include an electrophysiologist, an EP laboratory manager, an outpatient clinic manager, an EP nurse, advanced practice providers, a device technician, an anesthesiologist, and an imaging team to provide insights into various aspects of the workflow.

"This team can clarify, interpret, iterate and disseminate policies, and also provide the necessary operational support to plan and successfully execute the reboot process as the efforts to contain COVID-19 continue," the writing group says.

A mandatory component of the reboot plan should be planning for a second wave of the virus.

"We will have to learn to create relatively COVID-19 safe zones within the hospitals to help isolate patients from second waves and yet be able to provide regular care for non–COVID-19 patients," the writing group says.

"Our main goal as health care professionals, whether we serve in a clinical, teaching, research, or administrative role, is to do everything we can to create a safe environment for our patients so that they receive the excellent care they deserve," they conclude.

Defining Moment for Remote Arrhythmia Monitoring

In a separate report, an international team of heart rhythm specialists from the Latin American Heart Rhythm Society, the HRS, the European Heart Rhythm Association, the Asia Pacific Heart Rhythm Society, the AHA, and the ACC discuss how the pandemic has fueled adoption of telehealth and remote patient management across medicine, including heart rhythm monitoring.

Their report is simultaneously published in Circulation: Arrhythmia and Electrophysiology, EP Europace, the Journal of the American College of Cardiology, the Journal of Arrhythmia, and Heart Rhythm.

The COVID-19 pandemic has "catalyzed the use of wearables and digital medical tools," and this will likely define medicine going forward, first author Niraj Varma, MD, PhD, Cleveland Clinic, Ohio, told Medscape Medical News.

He noted that the technology has been available for some time, but the pandemic has forced people to use it. "Necessity is the mother of invention, and this has become necessary during the pandemic when we can't see our patients," said Varma.

He also noted that hospitals and physicians are now realizing that telehealth and remote arrhythmia monitoring "actually work, and regulatory agencies have moved very swiftly to dissolve traditional barriers and will now reimburse for it. So it's a win-win."

Varma and colleagues say the time is right to "embed and grow remote services in everyday medical practice worldwide." In their report, they offer a list of commonly used platforms for telehealth and examples of remote electrocardiogram and heart rate monitoring devices.

Development of the three reports had no commercial funding. Complete lists of disclosures for the writing groups are available in the original articles.

JACC Cardiovasc Imaging. Published online June 12, 2020. Abstract

JACC Clin Electrophysiol. Published online June 12, 2020. Abstract

J Am Coll Cardiol. Published online June 11, 2020. Abstract

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