The following are key points to remember from this position paper from the European Society of Cardiology (ESC) regarding coronavirus disease 2019 (COVID-19) in adults with congenital heart disease (ACHD):

1. ACHD may be at increased risk for complications with COVID-19. Although certain ACHD diagnoses are felt to be at particularly high risk, solid evidence as to which patients are at the greatest risk is currently lacking.
2. The heterogeneous nature of the ACHD patient population suggests the need for an individualized approach to risk stratification.
3. Several multicenter projects are currently underway to better understand the impact of COVID-19 on patients with congenital heart disease.
4. Based on expert opinion, the ESC working group has identified low-, moderate-, and high-risk patient groups. Importantly, this stratification is dependent both on anatomic complexity as well as on an individual patient’s physiologic status. For example, a patient with simple disease with significant symptoms or heart failure is likely higher risk than a patient with complex disease and excellent clinical status.
5. Low-risk patients include those patients with biventricular anatomy and normal ventricular function, no significant arrhythmias, no pulmonary hypertension, good functional class, and no significant residual shunts or valvular lesions.
6. High-risk patients are those with univentricular heart or complex uncorrected or palliated anatomy or those with overt heart failure, cyanosis, pulmonary hypertension, severe ventricular dysfunction, and significant valvular heart disease.
7. Moderate-risk patients include those not meeting low- or high-risk criteria, and applies to the majority of patients with moderate-complexity disease. This group also includes those with chromosomal abnormalities.
8. It is hoped that emerging data regarding outcomes of ACHD patients with COVID-19 will continue to inform approaches towards risk stratification and patient management.
9. The working group recommends that low-risk ACHD patients follow standard protection measures and do not require restrictions from work or school. In the event of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, these patients are likely candidates for home management in consultation with an ACHD center with plan for early admission in case of clinical deterioration.
10. The working group recommends that moderate-risk patients undergo individualized risk assessment and that they reduce nonessential contact with the general population and have individualized discussions with their workplace regarding protective measures. These patients should be considered for early admission in the event of SARS-CoV-2 along with close involvement with an ACHD team.
11. For patients in the high-risk group, the working group recommends meticulous social distancing and avoidance of direct contact with clients or students when possible, with a preference for home office work. In the event of SARS-CoV-2 infection, early admission even in asymptomatic patients could be considered alongside consultation with the ACHD team. Early planning for treatment strategies, including the impact of treatments on a patient’s specific cardiac physiology, is recommended.
12. Specific concerns for Fontan patients include intolerance to elevated pulmonary artery pressures seen with acute respiratory distress syndrome, poor tolerance of positive pressure ventilation, and a propensity for thromboembolic complications, which can be seen with COVID-19.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Pulmonary Hypertension, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Hypertension

Keywords: Arrhythmias, Cardiac, Cardiomyopathies, Chromosome Aberrations, Coronavirus, COVID-19, Cyanosis, Fontan Procedure, Heart Defects, Congenital, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Positive-Pressure Respiration, Primary Prevention, Risk Assessment, Thromboembolism, Ventricular Dysfunction

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