Restructuring Structural Heart Disease Practice During the COVID-19 Pandemic: JACC Review Topic of the Week

Abstract

Patients with structural heart disease are at increased risk of adverse outcomes from the coronavirus disease-2019 (COVID-19) due to advanced age and comorbidity. In the midst of a global pandemic of a novel infectious disease, reality-based considerations comprise an important starting point for formulating clinical management pathways. The aims of these "crisis-driven" recommendations are: 1) to ensure appropriate and timely treatment of structural heart disease patients; 2) to minimize the risk of COVID-19 exposure to patients and health care workers; and 3) to limit resource utilization under conditions of constraint. Although the degree of disruption to usual practice will vary across the United States and elsewhere, we hope that early experiences from a heart team operating in the current global epicenter of COVID-19 may prove useful for others adapting their practice in advance of local surges of COVID-19.

Keywords: COVID-19; heart team; structural heart disease; valve center.

Graphical abstract

Figure 1

Triaging Patients With Structural Heart Disease AS = aortic stenosis; MR = mitral regurgitation; NYHA = New York Heart Association; PV = peak velocity.

Figure 2

Potential Scenarios (A) In this scenario, the site might choose to perform procedures for patients in tiers 1 and 2, but should defer procedures for patients in tier 3 until later in the pandemic. (B) In this scenario, tier 1 patient procedures should only be done after careful assessment of risk/benefit profile and consideration of futility. Tier 2 patient procedures can be done selectively, favoring younger, low-risk patients with ideal anatomy. Procedures for patients in tier 3 should only be done late in the course of the pandemic. AS = aortic stenosis; COVID-19 = coronavirus disease-2019; ICU = intensive care unit.

Central Illustration

Suggested Framework for Decision-Making Patient characteristics, procedural complexity, and hospital resource constraints should be plotted in their respective quadrants. The larger the resulting polygon, the stronger the recommendation to defer the procedure.

Figure 3

Illustrative Cases (A) Example 1 is a 62-year-old woman with ideal TAVR anatomy and NYHA class IV symptoms, presenting to a hospital system facing moderate resource constraints. It is reasonable to proceed with this procedure urgently. (B) Example 2 is an 88-year-old morbidly obese woman with multiple comorbidities, nonideal TAVR anatomy and NYHA class IV symptoms, in the setting of severe resource constraints. This procedure should be deferred. Palliative care, rather than intervention, may be a more appropriate course of action.

Figure 4

Procedural Considerations When Doing Structural Heart Cases During the Pandemic COVID-19 = coronavirus disease-2019; POD #1 = post-operative day #1; PPM = permanent pacemaker; TAVR = transcatheter aortic valve replacement.

Figure 5

Considerations During Each Stage of the Pandemic ∗PPE includes use of N95 respirators and face shields in addition to surgical gowns and gloves. HCW = health care workers; PPE = personal protective equipment.