How to Prioritize Structural Heart Interventions During Pand
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Adaptations in the catheterization laboratory and beyond are needed to ensure timely treatment of people with structural heart disease (SHD) while minimizing the risk of COVID-19 exposure to patients and healthcare workers, according to the American College of Cardiology (ACC) and Society for Cardiovascular Angiography and Interventions (SCAI).

In early March, the New York group cancelled all procedures over the next 2 months then re-prioritized patients under a three-tier system:

Tier 1 (emergent/urgent): highest-risk cases requiring a procedure within days or 1-2 weeks (e.g., severe aortic stenosis with New York Heart Association [NYHA] Class IV symptoms, recurrent/refractory heart failure requiring hospitalization, or recurrent syncope)

Tier 2 (semi-Urgent): cases requiring close monitoring at weekly intervals and an intervention within 1-2 months (e.g., severe aortic stenosis with rapidly progressive or worsening NYHA Class III symptoms; severe tricuspid regurgitation with worsening NYHA Class IV symptoms and evidence of progressive organ system dysfunction)

Tier 3 (elective): lower-risk cases that may be postponed for 2 months or longer (e.g., severe aortic stenosis with NYHA Class I-II symptoms; severe mitral regurgitation with NYHA Class I-II symptoms on optimal pharmacotherapy; and severe tricuspid regurgitation with NYHA Class I-III symptoms on medical pharmacotherapy)

Changes in the Procedural Suite:

ACC and SCAI recommend that those who scrub for procedures don PPE suitable for airborne precautions, including an N95 respirator and a face shield, given the risk of emergent intubation and need for cardiopulmonary resuscitation.

"If a patient is planned for an emergent percutaneous mitral valve repair procedure, on-table TEE will suffice in case planning at experienced centers. For any high-risk SHD procedure requiring interventional imaging support with TEE, emphasis must be placed on availability of full PPE for the interventional imager," the group recommended.

"In the absence of sufficient PPE, alternative imaging modalities should be considered (intracardiac echo if possible) as there is high risk of COVID-19 exposure with TEE performance," according to the ACC/SCAI guidance.

And in aortic valve replacement, transcatheter procedures may be a reasonable alternative to surgery to conserve ICU beds and to reduce the risk of COVID-19 exposure with inpatient admission.