ACC/SCAI Consensus Document Guides Triage For Structural Heart Disease During COVID-19 Pandemic

The ACC and Society for Cardiovascular Angiography and Interventions (SCAI) has published guidance for triaging patients with valvular and structural heart disease (SHD), recognizing the challenge of balancing the risk of a delaying a needed procedure against the risk of a susceptible patient being brought into the hospital during the COVID-19 pandemic. The document, authored by the ACC Interventional Council, SCAI, and ACC Cardiac Surgery Team and Leadership Council, was published in JACC: Cardiovascular Interventions.

A framework is provided to guide decision-making about the appropriate timing for an intervention, despite the ongoing pandemic, and addresses the triage of patients needing TAVR and percutaneous mitral valve repair, as well as procedural issues and considerations for the function of the structural heart disease team.

The authors note that an added concern is the geographical variation in the peak of the pandemic in the U.S., which will pose distinct challenges for rescheduling procedures, potentially for many months, as normal health care operations are restored.

Four general priorities are: 1) minimize exposure to coronavirus for SHD patients and the structural interventional team; 2) maintain high quality and durable structural interventional outcomes in those who require a procedure during the pandemic; 3) reduce the risk that these SHD patients use resources that might be needed for COVID-19 patients; and 4) prevent delay of intervention in patients at particularly high risk for clinical deterioration, heart failure, and death. Local clinical judgment based on the impact of the COVID-19 pandemic in the region and institution should ultimately guide the evaluation and treatment pathway.

Regarding TAVR, the writing group proposes timing for patients with symptomatic severe aortic stenosis (AS), minimally symptomatic severe to critical AS, and asymptomatic severe to critical AS. Weekly telephone follow-up for patients whose procedures are deferred is recommended, and convening weekly virtual TAVR team meetings, with a single interventional cardiologist and cardiac surgeon assuming a leadership role and authority to arbitrate challenging cases.

Recommendations for transcatheter mitral valve procedures includes five patient groups who should be considered for edge-to-edge repair during the pandemic; deferral of valve-in-valve replacement.

Also addressed is paravalvular leak closure, other SHD interventions, and intraprocedural imaging. Telehealth consultations should be considered and coordination of pre-procedure visits and imaging to a single visit. A coordinated multidisciplinary effort needs to occur to safely defer and monitor SHD patients requiring interventional therapies.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention

Keywords: Coronavirus, COVID-19, Mitral Valve, Triage, Pandemics, Transcatheter Aortic Valve Replacement, Follow-Up Studies, Coronavirus Infections

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