Outpatient management of heart valve disease following the COVID-19 pandemic: implications for present and future care

Heart team consultations for patients with severe coronary artery disease or valvular heart disease in the era of the COVID-19 pandemic: a single-center experience

Introduction

The Heart Team (HT) as a group of experienced specialists is responsible for optimal decision-making for high-risk cardiac patients. The aim of this study was to investigate the impact of the COVID-19 pandemic on HT functioning.

Methods

In this retrospective, single-center study, we evaluated the cooperation of HT in terms of the frequency of meetings, the number of consulted patients, and the trends in choosing the optimal treatment strategies for complex individuals with severe coronary artery disease (CAD) or valvular heart disease (VHD) before and during the COVID-19 pandemic in Poland.

Results

From 2016 to May 2022, 301 HT meetings were held, and a total of 4,183 patients with severe CAD (2,060 patients) or severe VHD (2,123 patients) were presented. A significant decrease in the number of HT meetings and consulted patients (2019: 49 and 823 vs. 2020: 44 and 542 and 2021: 45 and 611, respectively, P < 0.001) as well as changes in treatment strategies-increase of conservative, reduction of invasive (2019: 16.7 and 51.9 patients/month vs. 2020: 20.4 and 24.8 patients/month and 2021:19.3 and 31.6 patients/month, respectively, P < 0.001)-were demonstrated with the spread of the COVID-19 pandemic. As the pandemic slowly receded, the observed changes began to return to the pre-pandemic trends.

Conclusions

The COVID-19 pandemic resulted in a decrease in the number of HT meetings and consulted patients and significant reduction of invasive procedures in favor of conservative management. Further studies should be aimed to evaluate the long-term implications of this phenomenon.

International consensus statement on challenges for women in cardiovascular practice and research in the COVID-19 era

The challenges to academic and professional development and career advancement of women in cardiology (WIC), imposed by the pandemic, not only impinge the female cardiologists' "leaky pipeline" but also make the "leakiness" more obvious. This consensus document aims to highlight the pandemic challenges WIC face, raise awareness of the gender equity gap, and propose mitigating actionable solutions derived from the data and experiences of an international group of female cardiovascular clinicians and researchers. This changing landscape has led to the need for highly specialized cardiologists who may have additional training in critical care, imaging, advanced heart failure, or interventional cardiology. Although women account for most medical school graduates, the number of WIC, particularly in mentioned sub-specialties, remains low. Moreover, women have been more affected by systemic issues within these challenging work environments, limiting their professional progression, career advancement, and economic potential. Therefore, it is imperative that tangible action points be noted and undertaken to ensure the representation of women in leadership, advocacy, and decision-making, and increase diversity in academia. Strategies to mitigate the negative impacts of the pandemic need to be taken during this COVID-19 pandemic to ensure WIC have a place in the field of Cardiology.

Fourteen-Year Temporal Trends in Patients Hospitalized for Mitral Regurgitation: The Increasing Burden of Mitral Valve Prolapse in Men

Mitral regurgitation (MR) is the second most common valvular heart disease in Europe. The aging of the population and the increase in post-infarction survival could increase the prevalence of MR. To estimate the burden of patients hospitalized for MR in France in 2019 and temporal trends by etiology and sex from 2006 to 2020, we selected all patients hospitalized for MR using the national hospital database. In 2019, 49.2% of such patients had mitral valve prolapse (MVP), 17.1% had ischemic MR, 9.9% had rheumatic MR and 4.4% had MR with cardiomyopathy. The mean age of MVP patients was 67.8 years, and 34% were women. Among 89% of MVP inpatients who had received mitral valve repair or replacement, 55% received surgical repair, 13% received percutaneous repair and 25% received replacement. The all-cause mortality of one year after a mitral procedure of MVP was 5.4%. Among ischemic MR inpatients, 29% have had a mitral valve replacement, 16% a surgical repair and 19% a percutaneous repair. Between 2006 and 2019, the age-standardized rates of patients hospitalized for MVP have increased by 60%, especially in men (+80%) with 5.3/100,000 Person-Years (PY). The age-standardized rates of patients hospitalized for ischemic MR have increased by 25% with 1.8/100,000 PY; that of rheumatic MR has decreased by 36%. The study found that the burden of MVP in hospitals has increased substantially, especially among men. These results emphasize the need to monitor these temporal trends and anticipate care needs in the coming years.

Heart valve disease: a journey of discovery

In the centenary year of the British Cardiovascular Society (BCS), this review article outlines the influence of UK cardiologists and surgeons on the field of heart valve disease, many of whom can rightly claim 'world firsts' in the field. From the description of endocarditis as we know it today at the turn of the 20th century, to the first mitral valvotomy, heart valve replacement and invention of the Ross procedure. These advances have transformed the outlook of patients with symptomatic valve disease from palliation and certain death to curative treatment and near normal life expectancy. Transcatheter aortic valve implantation (TAVI) was adopted early in the UK, and thanks to the comprehensive national database, the UK TAVI registry is one of the world's largest, contributing real-world patient data to inform clinical practice. The more recent concepts of 'Heart Valve Centres of Excellence' and specialist valve clinics have been developed by the BCS-affiliated British Heart Valve Society which continues to drive improved standards for patients with heart valve disease. The next 100 years will no doubt be equally thrilling in terms of innovation for heart valve disease, with artificial intelligence, transcatheter therapies and cutting-edge technology continuing to improve patient care and clinical outcomes.

Changes to transcatheter aortic valve replacement (TAVR) services during the first wave of the COVID-19 pandemic: A single centre experience from United Kingdom tertiary hospital

AIMS

COVID-19 had a devastating impact on patients with severe aortic stenosis (AS). Like many cardiac procedures, transcatheter aortic valve replacement (TAVR) services were suspended during the first wave of COVID-19. We took the opportunity to evaluate the clinical outcomes and identify any delays at different stages of the TAVR pathway during the COVID-19 pandemic.

METHODS

Prospectively collected data on 210 consecutive TAVR patients between March 2019 and March 2021 were analysed. We compared the clinical outcomes and 30-day mortality rates of TAVR cases pre-pandemic and during the pandemic. We also looked to identify any time lags from the initial referral to respective stages of the TAVR workup.

RESULTS

A total of 134 patients underwent TAVR prior to the national lockdown (March 2019-March 2020), compared to 76 patients during COVID-19 (April 2020-April 2021). Success rates of TAVR were similar (99% prior to the pandemic and 97.4% during COVID-19). The 30-day survival rates were 98.6% and 94.7%, respectively. Median length of stay post TAVR was 2 days during COVID-19 and 2.5 days prior to the pandemic (p = 0.064). Patients were seen quicker in clinic (median of 33 days) during COVID-19, compared to 51 days before COVID-19 (p = 0.044). No significant difference in times from referral to discussion at TAVR multidisciplinary team (MDT) meetings, CT Aortogram and TAVR implantation, in both groups.

CONCLUSIONS

Reconfiguring the patient pathway during COVID-19 allowed TAVR to be performed safely, with a similar success rate and no excess complications or increased 30-day mortality. There proved to be no delay in the respective stages of patient TAVR workup, during the pandemic.

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

Creating a better journey of care for patients with heart valve disease

Heart valve disease has been described as ‘the next cardiac epidemic’, with prevalence expected to double by 2040 and triple by 2060 due to the ageing of the population. Yet until now, it has been characterized by scarce data, limited research, and low general awareness compared with other cardiovascular diseases. Effective treatment options exist for heart valve disease, and early detection and treatment can dramatically change disease progression, improve quality of life, and reduce mortality. Unfortunately, in too many patients, heart valve disease is undetected, undiagnosed, untreated, or treated too late, leading to avoidable deaths and costs, and significant compromises to people’s quality of life. These gaps in the patient pathway can be remedied through appropriate policy action, with a focus on: early detection and diagnosis; timely intervention; patient-centred follow-up care; patient engagement and empowerment; psychological support; and better data to guide practice. Ensuring all patients have access to appropriate diagnosis and care without delays is imperative as we look towards rebuilding stronger and more resilient health systems, and ‘build back better’ after the coronavirus disease-19 pandemic.

Late phase of COVID-19 pandemic in General Cardiology. A position paper of the ESC Council for Cardiology Practice

Cardiovascular (CV) engagement in coronavirus disease 2019 (COVID-19) is a huge determinant of prognosis during the acute phase of the disease. However, little is known about the potential chronic implications of the late phase of COVID-19 and about the appropriate approach to these patients. Heart failure, type 1 and type 2 myocardial infarction, arrhythmias, myocarditis, pulmonary fibrosis, and thrombosis have been shown to be related to severe acute respiratory syndrome coronavirus 2 infection, and a 'long COVID-19' illness has been recognized with fatigue, chest pain, and dyspnoea among the most frequent symptoms reported after discharge from hospital. This paper focuses on some open questions that cardiologists are going to face during the next months in a general cardiology outpatient clinic, in particular how to evaluate a 'post-COVID' patient during follow-up of CV complications of the acute phase and how to manage new CV symptoms that could be the consequence, at least in part, of heart/vessels and/or lung involvement of the previous virus infection. Present symptoms and signs, history of previous CV disease (both preceding COVID-19 and occurring during viral infection), and specific laboratory and imaging measurements during the acute phase may be of interest in focusing on how to approach the clinical evaluation of a post-COVID patient and how to integrate in our standard of care the new information on COVID-19, possibly in a multidisciplinary view. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae.