How to Resume Elective CV Interventions as COVID-19 Rages On

As the pandemic drags on, lessons learned in how to address COVID-19 and its fallout mean that not only acute but also elective procedures, including cardiac interventions, are now possible—when carefully planned. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) last week released advice on how to balance clinical need against safety, with an eye toward regional differences in resources.

The statement—dedicated to elective cardiac invasive procedures—follows a previous paper, from June 2020, that focused on acute coronary syndromes. Both were published in EuroIntervention.

“We are already facing a ‘second wave’ of infections and we might be dealing during the next months with a ‘third wave’ and subsequently new waves,” Alaide Chieffo, MD (San Raffaele Scientific Institute, Milan, Italy), and colleagues write in the latest document. “In this context, the interplay between the pandemic stage, the availability of healthcare resources, and the priority of specific cardiac disorders is crucial.”

Davide Capodanno, MD, PhD (University of Catania, Italy), EuroIntervention’s editor-in-chief, told TCTMD that the EAPCI statement looks to the future. “In the first wave, there were lockdowns, so of course all the procedures were stopped. But now we are in a phase in which we have to live together with this situation and of course we cannot stop the elective procedures.”

Chieffo said that growing experience in the past year informed their approach. PCI for left main disease or in patients with angina at rest or with mild exertion, for example, and procedures for symptomatic valve disease “clearly we could not postpone until the end of this pandemic,” she explained to TCTMD.

But a key lesson has been that even less urgent procedures can’t be skipped in the long term. “What we’ve learned is that focusing just on COVID patients and acute coronary syndromes, leaving behind all the other interventions, proved to increase morbidity . . . with all patients coming back with worse clinical condition,” she noted. Clinicians today are facing patients with more-severe symptoms who would have been treated at earlier stages in their disease.

What we’ve learned is that focusing just on acute coronary syndromes and leaving behind all the other interventions proved to increase morbidity. Alaide Chieffo

Much like the widely cited “missing STEMIs” phenomenon, lack of care—even in elective settings—can harm patients, Capodanno agreed. “Some patients are scared of the hospital, which is understandable, but we have to do our best to make public that it’s different from the first wave. Because during the first wave, everyone was unprepared.”

This is no longer the case, added Capodanno. “Things are a little bit back normal now.”

Key Concerns and Flexibility

The document’s authors hail from a wide swath of nations affected to various degrees by COVID-19: Italy, Germany, Belgium, the United Kingdom, France, the Netherlands, Poland, Spain, Portugal, Switzerland, Sweden, and Israel. Chieffo described it as a “flexible model,” designed to account for Europe’s heterogeneity.

Hopefully a document like this will become a memory of the past. Davide Capodanno

The EAPCI group advises that plans for elective procedures should consider three key aspects: pandemic stage (eg, level of COVID-19 transmission), local availability of healthcare resources (including ICU capacity), and awareness as to which patients/procedures should be prioritized.

The latter component—prioritization—may be the most difficult, Chieffo noted. To aid in decision-making, the authors have created a table that separates procedures based on timing into urgent (within days), semi-urgent (within < 3 months), and elective (beyond 3 months) for ischemic heart disease, valvular heart disease, and “other” interventions such as those to address paravalvular leak or patent foramen ovale.

“The highest priority should be given to urgent procedures with documented prognostic benefit,” they write, adding, “Importantly, the benefit of a certain procedure should be put in the context of the individual patient and may range from maximum to limited or none, in terms of both life expectancy and quality of life.” Criteria should be consistent within regions and not influenced by medical insurance, gender, ethnicity, or religious/political beliefs, the authors say.

‘Testing, Testing, Testing’

Through all of these challenges, it’s important to “reassure those individuals who require medical help that they will be treated safely,” the document urges.

What will enable this, said Chieffo, is “testing, testing, testing,” which the document covers in detail. This is what “allows the hospital to maintain the differentiation between ‘cold’ and ‘hot’ areas necessary to avoid infection of patients admitted for elective procedures,” she said.

Hot areas treat patients who test positive for COVID-19 or are presumed (due to known exposure or symptoms) to have the disease, with personal protective equipment similar no matter whether the cardiovascular interventions are elective or urgent, she explained. Cold areas, on the other hand, are normal wards for those who test negative. “This system allows better use of PPE” by targeting the situations that require it, Chieffo noted. “Once we have negative results, [these individuals] should be treated as all the other patients—they wear a medical mask and the operator wears a medical mask, and that’s it.”

Capodanno said the EAPCI paper provides a framework that will be useful over the long term as the pandemic evolves, as well as advice from the hardest-hit countries for those in earlier stages. That said, “hopefully a document like this will become a memory of the past,” he added. “This is what everyone hopes.”