How Three Cardiac Procedures Changed in the COVID Era

Christine Kilgore

August 03, 2020

In late March, when Virginia's governor directed that all elective surgeries be postponed, Wayne Batchelor, MD, and his colleagues at the Inova Heart and Vascular Institute in Falls Church, Virginia, canceled about two thirds of their transcatheter aortic valve replacement (TAVR) procedures.

They then categorized patients by tiers to gauge which procedures could safely be postponed and to guide triaging. Although they did not deviate from the practice of having both an interventional cardiologist and a cardiothoracic surgeon present for TAVR, they slimmed down preprocedural testing when feasible and delayed some 30-day post-TAVR echocardiographic assessments. "It was a delicate dance, very difficult dance. But luckily, we were able to navigate the challenges effectively," said Batchelor, the institute's director of interventional cardiology and interventional cardiology research.

Wayne Batchelor, MD, in face protection.

A "system capacity dashboard" that merged bed and staffing data from interventional cardiology spaces with cardiovascular and noncardiovascular ICU beds, operating rooms, and other resources — and daily cross-department meetings — enabled them to proceed with the most urgent TAVR procedures while "keeping a buffer of ICU beds to accommodate an anticipated surge of COVID-19," he explained.

Such adaptations in cardiac procedures and processes are occurring in hospitals across the country as efforts are made to minimize the risk of COVID-19 exposure for patients and staff. Batchelor is one of four cardiologists who shared their experiences and advice with Medscape on common cardiac procedures across three locales: TAVR in Virginia, percutaneous coronary intervention (PCI) in New York City, and atrial fibrillation (AF) ablation in Kentucky.

More on TAVR in Virginia

Inova's framework for triaging structural heart disease interventions (largely TAVR and/or percutaneous mitral valve repair) comprised three tiers. Tier 1 captured "emergent cases that had to be done, no questions asked," Batchelor said. For TAVR, these were inpatients with severe to critical symptomatic aortic stenosis and advanced congestive heart failure who could not safely be discharged and other patients "with refractory symptoms of heart failure that were compelling." Many had associated left ventricular systolic dysfunction.

Patients whose procedures could be delayed 14 to 30 days were placed in tier 2, and patients who "we felt were fairly stable and could wait at least 30 days" were placed in tier 3. "For TAVR, a tier 3 patient might be the one...who has severe aortic stenosis but is walking around and doing well at home with only stable exertional symptoms," he said.

Patients whose procedures were delayed were contacted weekly by the valve clinic's advanced practice practitioners through video visits or telephone calls, and tier categorization was reevaluated if symptoms worsened. "We had to keep in close contact with them," Batchelor said. "These patients can deteriorate quite rapidly and sometimes without much warning."

Virtual video visits were often used for 30-day postprocedural follow-ups, taking the place of in-person visits during which post-TAVR echocardiographic assessments would normally be performed. "For follow-up, we'd often just do a quick visit to check the vascular access site within 7 to 10 days, and then if they were doing okay, we'd delay the 30-day echo to a later time frame," he said.

Preprocedural testing was streamlined to minimize the number of patient-provider interactions. Pulmonary function testing and pre-TAVR catheterization were omitted unless absolutely necessary. "A TAVR CT angiogram [performed within the prior year] is the only test you really absolutely need," Batchelor said. "We were much less likely to order a heart catheterization unless the patient was having angina and high risk or suspicion for significant coronary artery disease."

This approach was not associated with any compromise in postprocedural outcomes, he noted. Prior to the pandemic, Inova routinely employed a minimalist approach to TAVR with moderate conscious sedation and avoided transesophageal echocardiography — steps that were recommended for structural heart procedures in the COVID-19 era in a published review by the heart team at New York–Presbyterian Hospital/Columbia University Irving Medical Center/New York–Presbyterian.

The New York review is useful for cardiologists in areas with rising case burdens of COVID-19, Batchelor said, as is a position statement he coauthored from the American College of Cardiology (ACC) and the Society for Cardiology and Angiography Interventions (SCAI) on triage considerations for structural heart disease interventions during the pandemic.

TAVR's resource-heavy nature made the "system capacity dashboard" and daily meetings critical, Batchelor explained. At one point during the hold on elective procedures, the Falls Church INOVA facility had approximately 300 patients with COVID-19, a significant proportion of whom were in cardiac ICU beds.

"Everyone has to be flexible and learn," he said. "We trained our cardiologists on managing ventilators in case some of the CC staff got ill or were overwhelmed by the surge."

More than 2 months after the surge eased and the ban on elective surgery was lifted, Batchelor and his colleagues are still using the dashboard and continue to meet daily to discuss COVID-19 prevalence in the hospital and the community as they work through the backlog of delayed procedures. They also routinely review the status of COVID-19 testing for inpatients and outpatients and the donning and doffing of PPE.

"You have to communicate early and often across the whole system of care because you're competing for the same resources," he advised. "And you have to be flexible and reassess. A policy that works at the beginning of the pandemic might have to change."

PCI in New York City  

Before the pandemic, the cardiac catheterization laboratory at Mount Sinai Morningside Hospital in New York City handled a monthly average of 140 to 150 PCIs, including six to 10 primary PCIs for ST-segment elevation myocardial infarction.

When electives were halted by the hospital in March and the city became the global epicenter for COVID-19, the cath lab went quiet. "Even though we were still able to do urgent cases or emergent cases, the case volume dropped tremendously," said Jacqueline E. Tamis-Holland, MD, associate director of the cardiac catheterization laboratory and director of the interventional cardiology fellowship. "There weren't many outpatients in our hospital...and by late March and through April, there wasn't a single acute infarction."

She and Tak W. Kwan, MD, director of the cardiac catheterization laboratory and professor of medicine at Icahn School of Medicine at Mt. Sinai, were prepared to move true STEMI patients into the cath lab for primary PCI without delay unless the staff or system was overrun.

Tak Kwan, MD (L) and Jacqueline Tamis-Holland, MD (R) in modified face shield. "We used to wear glasses, but now that's not enough." They don more PPE if treating COVID patients or PUI.

That primary PCI remain the first-line treatment for STEMI even in cases of confirmed or suspected COVID-19 was recommended by SCAI guidance issued in March and by a consensus statement released by the SCAI, the ACC, and the American College of Emergency Physicians in April — and "we were very much of the same frame of mind," Tamis-Holland said.

Deciding which elective cases could not be delayed required a completely individualized approach, the cardiologists emphasized. Tamis-Holland had a few patients scheduled for elective PCI when the hold began, and "we spoke every few days or once a week in the beginning, then transitioned to once every 2 weeks," she said. "With medical therapy and given that they were relatively sedentary, my patients did okay [with the delays]."

For subsequent patients, she considered their symptoms or stress test results. "If it's someone who I'd [normally] wait until next week to schedule the cath, then we would wait 2 or 3 more weeks or a month more with careful monitoring," she said. "Certainly, there was a decrease in the number of abnormal stress tests that I referred to the cath lab during [the surge period]."

Kwan described one patient who had new-onset congestive heart failure in late March "with a markedly positive nuclear stress test." The patient was monitored with twice-weekly telemedicine visits and office visits, and a cardiac catheterization was performed in early May as an urgent elective case. "He had severe three-vessel and left main disease," he said. "Subsequently, CABG was done."

Signs remind patients of social distancing in the Mt Sinai waiting area.

There were no changes in the PCI procedure itself with regard to hospital stay (most elective cases at Mt. Sinai are same-day procedures) or staffing other than a ban on visiting students or residents. The most important changes during the surge — in addition to stocking enough PPE — concerned testing. Patients undergoing elective PCI are tested for the novel coronavirus 72 hours before the procedure, and rapid testing is performed in the emergency department for STEMI patients to determine patient disposition after the procedure.

"Until we have the results back, we should treat all patients as if they are a patient under investigation or have COVID," said Tamis-Holland, who helped develop emergency guidance on STEMI systems of care during the pandemic for the American Heart Association.

In early May, the hospital freed up additional space for cardiac care, allowing more "urgent-elective" PCIs to be performed. Some patients were reluctant to proceed, the cardiologists said, because of a no-visitor policy. In mid-June, the hold on elective procedures was lifted, and around the same time, the hospital shifted to a one-visitor policy. Still, some patients opted to continue with medical therapy.

Patients need to feel comfortable, and "there is a lag time from the time everything opens up and when patients get their stress tests and their evaluations and then arrive for PCI," said Tamis-Holland.

By mid-July, the cardiologists were anticipating an increase in complications from infarctions among patients who "waited them out at home" — heart failure or mitral valve regurgitation, for instance — but, in their hospital at least, "we haven't really seen that," she added.

AF Ablation in Kentucky

As New York experienced its surge, John Mandrola, MD, and other electrophysiologists across the Baptist Health system in Kentucky reached a consensus on how to categorize their procedures. Electrophysiology interventions were classified urgent, emergent, and truly elective in the event that the state's relatively low case burden of COVID-19 was to significantly worsen.

There was no doubt where AF ablation sat. "It's one of the most elective procedures there is" in terms of scheduling under normal circumstances, and it almost always requires an overnight stay and general anesthesia — factors that upped the ante on an elective classification, said Mandrola, who is a regular columnist at Medscape.

All AF ablations were deemed elective unless the patient required immediate hospitalization. For 8 to 10 weeks during the state's shutdown of elective care, Mandrola and his partner successfully monitored patients with phone calls. "To be honest," he said, "most patients did not want to have their afib ablation anyway until the pandemic slowed and they knew it was safe."

In some cases, patients reported that their symptoms were improving: "There are so many things to speculate about.... Was it that everyone took their foot off the accelerator?" Mandrola thinks that postpandemic outcomes analyses may drive more scrutiny of the necessity of some AF ablations and other procedures and tests. AF ablation "has its place but is probably overused," he said.

During the pause on electives, "the vast majority of procedures we did were pacemaker procedures," he said. "We also did some atrial flutter ablations and ablations for ventricular tachycardia and supraventricular tachycardia." In mid-July, as the COVID-19 case burden in Kentucky remained relatively low, Mandrola was "up to 120%" of his pre-COVID electrophysiology volume ― but ready to scale back again if needed.

Batchelor has received consulting fees from Boston Scientific, Abbott Medical, Medtronic, and V-wave. Kwan, Mandrola, and Tamis-Holland have disclosed no relevant financial relationships.

Christine Kilgore is a Falls Church, Virginia–based medical journalist whose work has appeared in publications that include Internal Medicine News, Ob.Gyn Times, Oncology Times, and The Washington Post.

This article is a collaboration between Medscape and MDedge.

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