Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic: An ACC/SCAI position statement

Examining lack of referrals to heart valve specialists as mechanisms of potential underutilization of aortic valve replacement

BACKGROUND

Recent studies suggest that aortic valve replacement (AVR) remains underutilized.

AIMS

Investigate the potential role of non-referral to heart valve specialists (HVS) on AVR utilization.

METHODS

Patients with severe aortic stenosis (AS) between 2015 and 2018, who met class I indication for intervention, were identified. Baseline data and process-related parameters were collected to analyze referral predictors and evaluate outcomes.

RESULTS

Among 981 patients meeting criteria AVR, 790 patients (80.5%) were assessed by HVS within six months of index TTE. Factors linked to reduced referral included increasing age (OR: 0.95; 95% CI: 0.94-0.97; P < .001), unmarried status (OR: 0.59; 95% CI: 0.43-0.83; P = .002) and inpatient TTE (OR: 0.27; 95% CI: 0.19-0.38; P < .001). Conversely, higher hematocrit (OR: 1.13; 95% CI: 1.09-1.16; P < .001) and eGFR (OR: 1.01; 95% CI: 1.00-1.02; P = .003), mean aortic valve gradient (OR: 1.03; 95% CI: 1.01-1.04; P < .001) and preserved LVEF (OR: 1.59; 95% CI: 1.02-2.48; P = .04), were associated with increased referral likelihood. Moreover, patients assessed by HVS referral as a time-dependent covariate had a significantly lower two-year mortality risk than those who were not (aHR: 0.30; 95% CI: 0.23-0.39; P < .001).

CONCLUSION

A substantial proportion of severe AS patients meeting indications for AVR are not evaluated by HVS and experience markedly increased mortality. Further research is warranted to assess the efficacy of care delivery mechanisms, such as e-consults, and telemedicine, to improve access to HVS expertise.

Impact of COVID-19 Surge Periods on Clinical Outcomes of Transcatheter Aortic Valve Implantation

Healthcare systems adopted various strategies to minimize the impact of the COVID-19 pandemic on clinical outcomes of patients with symptomatic severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI). We aimed to compare baseline characteristics and procedural and clinical outcomes of patients who underwent TAVI during COVID-19 surge periods with those of patients who underwent TAVI during the nonsurge and prepandemic periods. In the prospective Bern TAVI registry, the pandemic period was divided into surge and nonsurge periods on the basis of the mean number of occupied beds in the intensive care unit in each month and matched with 11 months immediately preceding the pandemic. A total of 1,069 patients underwent TAVI between April 1, 2019 and December 31, 2021. Patients who underwent TAVI during surge periods had a higher surgical risk (Society of Thoracic Surgeons predicted risk of mortality) than that of patients who underwent TAVI during nonsurge and prepandemic periods. Diagnosis-to-procedure time (in days) was longer for patients who underwent TAVI during the surge period than during the nonsurge and prepandemic periods (95.20 ± 121.07 vs 70.99 ± 72.25 and 60.46 ± 75.43, both p <0.001). At 30 days, all-cause mortality was higher in the surge than in the nonsurge group (4.9 vs 1.1%, hazard ratio 4.68, 95% confidence interval 1.55 to 14.10, p = 0.006), and in the surge than in the prepandemic group (4.9 vs 1.3%, hazard ratio 3.67, 95% confidence interval 1.34 to 10.11, p = 0.012). In conclusion, TAVI during COVID-19 surge periods was associated with higher Society of Thoracic Surgeons predicted risk of mortality score, delayed procedure scheduling, and increased 30-day mortality than that of TAVI during nonsurge and prepandemic periods.

Pre-cath Laboratory Planning for Left Atrial Appendage Occlusion - Optional or Essential?

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging. Furthermore, incorporation of computational modeling and artificial intelligence (AI) may yield promise. For optimal patient-centric procedural success, we advocate for standardized preprocedural imaging planning by physicians within the Heart Team as an essential part of LAAO.

National Trends of Structural Heart Disease Interventions from 2016 to 2020 in the United States and the Associated Impact of COVID-19 Pandemic

The Coronavirus Disease-2019 (COVID-19) pandemic placed an enormous strain on the healthcare system. Data on the impact of COVID-19 on the utilization and outcomes of structural heart disease interventions in the United States are scarce. The National Inpatient Sample from 2016 to 2020 was queried to identify adult admissions for transcatheter aortic valve replacement (TAVR), left atrial appendage occlusion (LAAO), and transcatheter end-to-end repair (TEER). The primary outcome was temporal trends of procedure utilization rate per 100,000 admissions over quarters from 2016 to 2020. The secondary outcomes were adjusted rates of in-hospital mortality, major complications, and length of stay (LOS). Among 434,630 weighted admissions (TAVR: 305,550; LAAO: 89,300; TEER: 40,160), 95,010 admissions (22%) were during the COVID-19 era. There was a decline during the second quarter of 2020 followed by an increase to the pre pandemic levels (TAVR: 220 to 253, LAAO: 57 to 109, and TEER: 31 to 36 per 100,000 admissions, Ptrend<0.001). There were no differences in the mortality or major complication rates. Median LOS has decreased in TAVR (4 days-1 day) and in TEER (3 days-1 day) but remained stable in LAAO (1 day). This nationwide analysis showed that structural heart disease interventions decreased during the early waves of COVID-19 pandemic. There was a significant reduction in hospital LOS without differences in in-hospital mortality or complication rates during the pandemic. These data suggest that hospitals adapted to the unprecedent challenges during the pandemic to provide advanced cardiac care to patients.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation

A European update on transcatheter aortic valve implantation (TAVI) in the COVID era

Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high-risk surgical cohorts but also in low-risk and intermediate-risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications.

Structured Allocation of Transcatheter Aortic Valve Replacement Patients during Coronavirus Disease 2019 Pandemic: Impact on Patient Selection and Clinical Results

Due to shortages of medical resources during the Coronavirus Disease 2019 (COVID-19) pandemic, an allocation algorithm for Transcatheter Aortic Valve Replacement (TAVR) was established. We investigated the impact on patient selection and procedural results. In total, 456 TAVR patients before (pre-COVID-19 group) and 456 TAVR patients after (COVID-19 group) the implementation of our allocation algorithm were compared. Concerning patient characteristics, the COVID-19 group revealed a higher rate of cardiac decompensations/cardiogenic shocks (10.5% vs. 1.3%; p < 0.001), severe angina pectoris (Canadian Cardiovascular Society (CCS) II, III and IV: 18.7% vs. 11.8%; p = 0.004), troponin elevation (>14 ng/L: 84.9% vs. 77%; p = 0.003) and reduced left ventricular ejection fraction (LVEF) (<45%: 18.9% vs. 12%; p = 0.006). Referring to procedural characteristics, more predilatations (46.3% vs. 35.1%; p = 0.001) and a longer procedural time (80.2 min (+/−29.4) vs. 66.9 min (+/−17.5); p < 0.001) were observed. The success rate was evenly high; no differences in safety parameters were reported. Examining the utilization of hospital resources, the COVID-19 group showed a shorter in-hospital stay (8.4 days (+/−5.9) vs. 9.5 days (+/−9.33); p = 0.041) and fewer TAVR patients were treated per month (39 (+/−4.55) vs. 46.11 (+/−7.57); p = 0.03). Our allocation algorithm supported prioritization of sicker patients with similar efficient and safe TAVR procedures. In-hospital stay could be shortened.

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalizations

Background

During the COVID-19 pandemic, in anticipation of a demand surge for high-care hospital beds, many hospitals postponed non-emergency interventions of cardiac patients.

Aim

The aim of this study was to assess the outcomes of cardiac patients whose non-emergency interventions had been deferred during the COVID-19 pandemic.

Methods

Patients whose non-emergency cardiac intervention had been cancelled between March 19th and April 30th, 2020 were included (study group). All patients were considered as deferrable according to current recommendations. Patients’ outcomes after 12 months were compared to a seasonal control group who underwent non-emergency interventions in 2019 as scheduled. The primary endpoint was a composite of emergency cardiovascular hospitalization and death. Secondary endpoints were levels of symptoms and cardiac biomarkers.

Results

Outcomes of 193 consecutive patients in the study group were assessed and compared to 216 controls. The primary endpoint occurred significantly more often in the study group (HR 2.42, 95%CI 1.63–3.61, p < 0.001). This was driven by an increase in hospitalizations. Subgroup analyses showed that especially patients with a deferred transcatheter heart valve intervention experienced early emergency hospitalization (HR 9.55, 95%CI 3.70–24.62, p < 0.001). These findings were accompanied by more pronounced symptoms and higher biomarker levels.

Conclusions

Deferral of non-emergency cardiac interventions to meet the higher demand for hospital beds during the COVID-19 crisis is associated with early emergency cardiovascular hospitalizations. Patients suffering from valvular heart disease especially constitute a vulnerable group. Consequently, our results suggest that current recommendations on the management of cardiovascular disease during the COVID-19 pandemic need revision.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02032-z.

Pre-cath Laboratory Planning for Left Atrial Appendage Occlusion - Optional or Essential?

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging. Furthermore, incorporation of computational modeling and artificial intelligence (AI) may yield promise. For optimal patient-centric procedural success, we advocate for standardized preprocedural imaging planning by physicians within the Heart Team as an essential part of LAAO.

ANMCO POSITION PAPER: cardio-oncology in the COVID era (CO and CO)

The COVID-19 pandemic and its impact on patients with cancer and cardiovascular disease have confirmed the particular vulnerability of these populations. Indeed, not only a higher risk of contracting the infection has been reported but also an increased occurrence of a more severe course and unfavourable outcome. Beyond the direct consequences of COVID-19 infection, the pandemic has an enormous impact on global health systems. Screening programmes and non-urgent tests have been postponed; clinical trials have suffered a setback. Similarly, in the area of cardiology care, a significant decline in STEMI accesses and an increase in cases of late presenting heart attacks with increased mortality and complication rates have been reported. Health care systems must therefore get ready to tackle the 'rebound effect' that will likely show a relative increase in the short- and medium-term incidence of diseases such as heart failure, myocardial infarction, arrhythmias, and cardio- and cerebrovascular complications. Scientific societies are taking action to provide general guidance and recommendations aimed at mitigating the unfavourable outcomes of this pandemic emergency. Cardio-oncology, as an emerging discipline, is more flexible in modulating care pathways and represents a beacon of innovation in the development of multi-specialty patient management. In the era of the COVID-19 pandemic, cardio-oncology has rapidly modified its clinical care pathways and implemented flexible monitoring protocols that include targeted use of cardiac imaging, increased use of biomarkers, and telemedicine systems. The goal of these strategic adjustments is to minimize the risk of infection for providers and patients while maintaining standards of care for the treatment of oncologic and cardiovascular diseases. The aim of this document is to evaluate the impact of the pandemic on the management of cardio-oncologic patients with the-state-of-the-art knowledge about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease (COVID-19) in order to optimize medical strategies during and after the pandemic.

Structural Heart Interventions During COVID-19

The spread of Coronavirus Disease 2019 (COVID-19) pandemic across the globe and the United States presented unprecedented challenges with dawn of new policies to reserve resources and protect the public. One of the major policies adopted by hospitals across the nations were postponement of non-emergent procedures such as transaortic valve replacement (TAVR), left atrial appendage closure device (LAAC), MitraClip and CardioMEMS. Guidelines were based mainly on the avoidable clinical outcomes occurring during COVID-19 era. As our understanding of the SARS-CoV-2 evolved, advanced cardiac procedures may safely continue through careful advanced coordination. We aim to highlight the new guidelines published by different major cardiovascular societies, and discuss solutions to safely perform procedures to improve outcomes in a patient population with high acuity of illness during the COVID-19 pandemic era.

Impact of COVID-19 pandemic on pediatric cardiac services in India

BACKGROUND

COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India.

AIMS

The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

METHODS

We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019.

RESULTS

The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%).

CONCLUSIONS

The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021

The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.

Cardiovascular Care of the Oncology Patient During COVID-19: An Expert Consensus Document From the ACC Cardio-Oncology and Imaging Councils

In response to the coronavirus disease 2019 (COVID-19) pandemic, the Cardio-Oncology and Imaging Councils of the American College of Cardiology offers recommendations to clinicians regarding the cardiovascular care of cardio-oncology patients in this expert consensus statement. Cardio-oncology patients-individuals with an active or prior cancer history and with or at risk of cardiovascular disease-are a rapidly growing population who are at increased risk of infection, and experiencing severe and/or lethal complications by COVID-19. Recommendations for optimizing screening and monitoring visits to detect cardiac dysfunction are discussed. In addition, judicious use of multimodality imaging and biomarkers are proposed to identify myocardial, valvular, vascular, and pericardial involvement in cancer patients. The difficulties of diagnosing the etiology of cardiovascular complications in patients with cancer and COVID-19 are outlined, along with weighing the advantages against risks of exposure, with the modification of existing cardiovascular treatments and cardiotoxicity surveillance in patients with cancer during the COVID-19 pandemic.

Coronavirus disease-19 and cardiovascular disease: A risk factor or a risk marker?

Severe acute respiratory syndrome coronavirus-2 causes the clinical syndrome of coronavirus disease of 2019 (COVID-19) which has become a global pandemic resulting in significant morbidity and mortality. While the virus primarily affects the respiratory system, it also causes a wide variety of complex cardiac manifestations such as acute myopericarditis, acute coronary syndrome, congested heart failure, cardiogenic shock and cardiac arrhythmias. There are numerous proposed mechanisms of cardiac injury, including direct cellular injury, pro-inflammatory cytokine storm, myocardial oxygen-demand mismatch, and systemic inflammation causing multi-organ failure. Additionally, medications commonly used to treat COVID-19 patients have various cardiovascular side effects. We aim to provide a succinct review about the pathophysiology and cardiac manifestations of COVID-19, as well as treatment considerations and the various adaptations made to the current healthcare structure as a result of the pandemic.

E-Triage Systems for COVID-19 Outbreak: Review and Recommendations

With population growth and aging, the emergence of new diseases and immunodeficiency, the demand for emergency departments (EDs) increases, making overcrowding in these departments a global problem. Due to the disease severity and transmission rate of COVID-19, it is necessary to provide an accurate and automated triage system to classify and isolate the suspected cases. Different triage methods for COVID-19 patients have been proposed as disease symptoms vary by country. Still, several problems with triage systems remain unresolved, most notably overcrowding in EDs, lengthy waiting times and difficulty adjusting static triage systems when the nature and symptoms of a disease changes. In this paper, we conduct a comprehensive review of general ED triage systems as well as COVID-19 triage systems. We identified important parameters that we recommend considering when designing an e-Triage (electronic triage) system for EDs, namely waiting time, simplicity, reliability, validity, scalability, and adaptability. Moreover, the study proposes a scoring-based e-Triage system for COVID-19 along with several recommended solutions to enhance the overall outcome of e-Triage systems during the outbreak. The recommended solutions aim to reduce overcrowding and overheads in EDs by remotely assessing patients' conditions and identifying their severity levels.

Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS)

The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD.

Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.

Performing elective cardiac invasive procedures during the COVID-19 outbreak: a position statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

The rearrangement of healthcare services required to face the coronavirus disease 2019 (COVID-19) pandemic led to a drastic reduction in elective cardiac invasive procedures. We are already facing a "second wave" of infections and we might be dealing during the next months with a "third wave" and subsequently new waves. Therefore, during the different waves of the COVID-19 pandemic we have to face the problems of how to perform elective cardiac invasive procedures in non-COVID patients and which patients/procedures should be prioritised. In this context, the interplay between the pandemic stage, the availability of healthcare resources and the priority of specific cardiac disorders is crucial. Clear pathways for "hot" or presumed "hot" patients and "cold" patients are mandatory in each hospital. Depending on the local testing capacity and intensity of transmission in the area, healthcare facilities may test patients for SARS-CoV-2 infection before the interventional procedure, regardless of risk assessment for COVID-19. Pre-hospital testing should always be conducted in the presence of symptoms suggestive of SARS-CoV-2 infection. In cases of confirmed or suspected COVID-19 positive patients, full personal protective equipment using FFP 2/N95 masks, eye protection, gowning and gloves is indicated during cardiac interventions for healthcare workers. When patients have tested negative for COVID-19, medical masks may be sufficient. Indeed, individual patients should themselves wear medical masks during cardiac interventions and outpatient visits.

Patient with valvular disease: evolving care patterns

COVID-19 has put each and every one at test. Cardiological clinics are facing constrained resources, limiting timely treatment of patients as usual. Patients with valvular heart disease are one of the most time sensitive patient populations, with delayed therapy possible leading to increased morbidity and mortality. Identifying and allocating the available resources to the most vulnerable patients is crucial in providing optimal patient care with prioritization of essential surgical or percutaneous procedures for valvular heart disease. Implementing telemedicine approaches might help to minimize non-essential physician-to-patient contact to ensure safety, for both patients and lastly but not least the treating physicians.

Safety and operational efficiency of restructuring and redeploying a transcatheter aortic valve replacement service during the COVID-19 pandemic: The Oxford experience

BACKGROUND

The risk of nosocomial COVID-19 infection for vulnerable aortic stenosis patients and intensive care resource utilization has led to cardiac surgery deferral. Untreated severe symptomatic aortic stenosis has a dismal prognosis. TAVR offers an attractive alternative to surgery as it is not reliant on intensive care resources. We set out to explore the safety and operational efficiency of restructuring a TAVR service and redeploying it to a new non-surgical site during the COVID-19 pandemic.

METHODS

The institutional prospective service database was retrospectively interrogated for the first 50 consecutive elective TAVR cases prior to and after our institution's operational adaptations for the COVID-19 pandemic. Our endpoints were VARC-2 defined procedural complications, 30-day mortality or re-admission and service efficiency metrics.

RESULTS

The profile of patients undergoing TAVR during the pandemic was similar to patients undergoing TAVR prior to the pandemic with the exception of a lower mean age (79 vs 82 years, p < 0.01) and median EuroScore II (3.1% vs 4.6%, p = 0.01). The service restructuring and redeployment contributed to the pandemic-mandated operational efficiency with a reduction in the distribution of pre-admission hospital visits (3 vs 3 visits, p < 0.001) and the time taken from TAVR clinic to procedure (26 vs 77 days, p < 0.0001) when compared to the pre-COVID-19 service. No statistically significant difference was noted in peri-procedural complications and 30-day outcomes, while post-operative length of stay was significantly reduced (2 vs 3 days, p < 0.0001) when compared to pre-COVID-19 practice.

CONCLUSIONS

TAVR service restructuring and redeployment to align with pandemic-mandated healthcare resource rationalization is safe and feasible.

Patient with heart failure: importance to treat valvular diseases

COVID-19 pandemic is causing an unprecedented burden on healthcare resources and this includes treatment of heart failure and valvular heart diseases (VHD). Percutaneous procedures have broadened the number of patients with VHD who could be treated. However, COVID-19 pandemic has challenged their implementation. The risk of in-hospital infection, resources reallocation, reduced access to hospital caused a substantial delay of VHD treatment with an increased risk of clinical worsening and mortality. Now, the pandemic is not ended and subsequent waves are likely. Reorganization of our healthcare resources is needed, including a proper algorithm for patients' prioritization, based on the severity of their valve disease, their life expectancy, complexity of the intervention, and the resources available. A wider use of telemedicine for patients' selection and follow-up and any measurement that can shorten the duration of the hospital stay must be adopted. Patients' and healthcare staff screening for COVID-19 and all needed procedures to prevent infection will continue to be mandatory. Percutaneous procedures, compared to surgery, are associated with a lower risk of infection and a lower need for in-hospital resources, including a shorter duration of hospital stay. This may favour their adoption when the risk of viral infection is high.

Impact of the Coronavirus (COVID-19) pandemic on surgical practice - Part 2 (surgical prioritisation)

The Coronavirus (COVID-19) Pandemic represents a once in a century challenge to human healthcare with over 4.5 million cases and over 300,000 deaths thus far. Surgical practice has been significantly impacted with all specialties writing guidelines for how to manage during this crisis. All specialties have had to triage the urgency of their daily surgical procedures and consider non-surgical management options where possible. The Pandemic has had ramifications for ways of working, surgical techniques, open vs minimally invasive, theatre workflow, patient and staff safety, training and education. With guidelines specific to each specialty being implemented and followed, surgeons should be able to continue to provide safe and effective care to their patients during the COVID-19 pandemic. In this comprehensive and up to date review we assess changes to working practices through the lens of each surgical specialty.

Consensus statement on coronary intervention during the coronavirus disease 19 pandemic: from the Korean Society of Interventional Cardiology

Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by the novel virus severe acute respiratory syndrome coronavirus 2. The first case developed in December, 2019 in Wuhan, China; several months later, COVID-19 has become pandemic, and there is no end in sight. This disaster is also causing serious health problems in the area of cardiovascular intervention. In response, the Korean Society of Interventional Cardiology formed a COVID-19 task force to develop practice guidelines. This special article introduces clinical practice guidelines to prevent secondary transmission of COVID-19 within facilities; the guidelines were developed to protect patients and healthcare workers from this highly contagious virus. We hope these guidelines help healthcare workers and cardiovascular disease patients around the world cope with the COVID-19 pandemic.

Patient care protocols and personal safety measures for health care professionals in cardiac catheterization rooms during the COVID-19 outbreak in the National Institute of Cardiology

The COVID‐19 was first described in late 2019 that quickly became a pandemic affecting every health system as we know it. The high transmissibility among humans represents a well‐known high burden of morbidity and mortality not only for cardiovascular patients but also for a higher risk between health care professionals that must deliver high‐quality care to them in any scenario, and cardiac catheterization rooms are no exception. This creates a new dilemma, minimize exposure to patients and health care professionals to COVID‐19 while maintaining high quality in cardiovascular therapeutics. In order to achieve this, several international recommendations on treatment algorithms modifications and in safety measures in the catheterization room have been published, always aiming to solve this dilemma in the best possible way. Hereby, we present a summary of the most recent treatment algorithms in the most important cardiovascular interventions (acute coronary syndromes, structural and congenital heart diseases) as well as specific safety measures with a step‐by‐step preparedness before and after any interventional procedure during COVID‐19 outbreak. The objective of this document is to inform and to train health care professionals that works in cardiac catheterization rooms on the risks as well on the plan for containment, mitigation, and response to the global situation of COVID‐19 infection in order to apply this in their own local work environments.

Guidelines for Balancing Priorities in Structural Heart Disease During the COVID-19 Pandemic

During the novel coronavirus disease 2019 (COVID-19) pandemic, many hospitals have been asked to postpone elective and surgical cases. This begs the question, “What is elective in structural heart disease intervention?” The recently proposed Society for Cardiovascular Angiography and Interventions/American College of Cardiology consensus statement is, unfortunately, non-specific and insufficient in its scope and scale of response to the COVID-19 pandemic.

We propose guidelines that are practical, multidisciplinary, implementable, and urgent. We believe that this will provide a helpful framework for our colleagues to manage their practices during the surge and peak phases of the pandemic.

General principles that apply across structural heart disease interventions include tracking and reporting cardiovascular outcomes, “healthcare distancing,” preserving vital resources and personnel, shared decision-making between the heart team and hospital administration on resource-intensive cases, and considering delaying research cases.

Specific guidance for transcatheter aortic valve replacement and MitraClip procedures varies according to pandemic phase. During the surge phase, treatment should broadly be limited to those at increased risk of complications in the near term. During the peak phase, treatment should be limited to inpatients for whom it may facilitate discharge.

Keeping our patients and ourselves safe is paramount, as well as justly rationing resources.

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Many elective and surgical cases have been postponed during the COVID-19 pandemic.

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We propose guidelines for managing structural heart disease during the pandemic.

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General principles include preserving vital resources and personnel.

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Specific guidance for TAVR and mitral valve repair changes with pandemic phase.

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Keeping our patients and ourselves safe and justly rationing resources is paramount.

Transcatheter Mitral Valve Repair with MitraClip for Severe Mitral Regurgitation and Cardiogenic Shock During the COVID-19 Pandemic

Transcatheter mitral valve repair with MitraClip (Abbott) is largely an elective procedure. The ongoing coronavirus disease 2019 (COVID-19) pandemic has posed challenges to health care systems; in many cases elective interventions have been curtailed. Patients with severe mitral regurgitation (MR) and cardiogenic shock are high-risk surgical candidates and at risk of a poor outcome without intervention. The American College of Cardiology (ACC) and the Society of Coronary Angiography and Interventions (SCAI) recently proposed joint guidance on triage of structural heart disease (SHD) interventions during the COVID-19 pandemic. We present two illustrative cases of severe MR and cardiogenic shock that were successfully treated with MitraClip amidst the COVID-19 pandemic with good outcomes at short term follow-up.

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COVID-19 has strained health care systems worldwide, and elective structural heart interventions have been curtailed

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Patients with severe mitral regurgitation (MR) and cardiogenic shock are high surgical risk and require timely intervention

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We highlight effective triage of mitral interventions during the pandemic in accordance to the SCAI/ACC consensus