Guidance for Cardiac EP During the COVID-19 Pandemic

Lakkireddy DR, Chung MK, Gopinathannair R, et al.
Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic From the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Circulation 2020;Mar 31:[Epub ahead of print].

The following are key points to remember from the Guidance for Cardiac Electrophysiology (EP) During the Coronavirus Pandemic document:

  1. SARS-CoV-2 is a highly infectious virus associated with significant morbidity and mortality. It is primarily transmitted by droplets and aerosol. Risk of the virus transmission is high for staff caring for patients in the setting of high flow oxygen, bronchoscopy, open tracheal suctioning, intubation, extubation, noninvasive positive pressure ventilation, endoscopy, or transesophageal echocardiography. COVID-19 has the potential to cause a myocardial injury with ≥17% of patients with elevated troponin and 23% noted to have heart failure.
  2. In the hospital, the number of individuals rounding should be minimized and social distancing should be practiced. Many EP consults may be completed without a face-to-face visit. Nonurgent or nonemergent procedures should be postponed to a later date. Resource conservation including personal protective equipment is of utmost importance.
  3. Urgent or emergent procedures should be performed based on risk-benefit analysis. Examples of such procedures are: ventricular tachycardia ablation for medically uncontrollable electrical storm; catheter ablation of incessant, hemodynamically significant, severely symptomatic supraventricular tachycardia not responding to antiarrhythmic drugs, rate control, and/or cardioversion; catheter ablation for Wolff-Parkinson-White syndrome or pre-excited atrial fibrillation with syncope or cardiac arrest; lead revision for malfunction in a pacemaker-dependent patient or implantable cardioverter-defibrillator (ICD) patient receiving inappropriate therapy; generator change in pacemaker-dependent patients at the elective replacement indicator or end-of-life pacemaker or ICD generator; secondary prevention ICD; pacemaker implant for complete heart block, Mobitz 2 atrioventricular (AV) block, or high-grade AV block with symptoms or severe symptomatic sinus node dysfunction with long pauses; lead/device extraction for infection; cardiac resynchronization therapy for severe refractory heart failure; cardioversion of highly symptomatic arrhythmias not controlled with medications; and transesophageal echocardiography for patients who need urgent cardioversion.
  4. For general anesthesia cases, elective intubation in the intensive care unit (ICU) or in a negative ventilation pressure room prior to entering the EP lab, same-day discharges after device implant should be considered to minimize the patient’s risk of nosocomial infection. To minimize transport of infected patients, direct current or chemical cardioversions can be performed at the bedside in the ICU. When feasible, patients with confirmed or suspected COVID-19 infection should be scheduled as the last case of the day and followed by extensive cleaning.
  5. In-person clinic visits should be avoided, and instead, tele-health/virtual visits should be adopted to minimize unnecessary exposure. The majority of incision site inspections post-device implantation or catheter ablation can be managed via tele-health utilizing a video conference or a picture.
  6. Remote device monitoring guidelines provide a Class I recommendation for routine use in patients. In-person device interrogation should be considered only in urgent or time-sensitive situations such as a clinically actionable abnormality that requires programming changes, evaluation of symptoms suspicious for arrhythmia in patients not already enrolled in remote monitoring, and urgent or emergent magnetic resonance imaging scanning.
  7. In case of a cardiopulmonary resuscitation, the number of personnel in the room should be minimized. All participants should have on personal protective equipment prior to entering the patient room. Early intubation and external mechanical compression devices should be considered.
  8. Hydroxychloroquine is known to block Kv11.1 channel and cause drug-induced QT prolongation. Its use should be avoided with concomitant QT-prolonging medications such as azithromycin, metabolic derangements, and renal failure. Of note, hydroxychloroquine has a long half-life of 40 days. The drug has been widely tolerated in most populations requiring the medication for malaria, rheumatoid arthritis, or systemic lupus erythematosus. Patients with severe renal insufficiency should have the dose reduced.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, Novel Agents, Statins, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Atrioventricular Block, Cardiac Electrophysiology, Coronavirus, COVID-19, Catheter Ablation, Cardiac Resynchronization Therapy, Cardiopulmonary Resuscitation, Defibrillators, Implantable, Echocardiography, Transesophageal, Electric Countershock, Heart Failure, Hydroxychloroquine, Renal Insufficiency, SARS Virus, Secondary Prevention, Severe Acute Respiratory Syndrome, Troponin, Ventilators, Negative-Pressure, Wolff-Parkinson-White Syndrome

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