Procedural Rescheduling Criteria in the Pandemic Era

Patients with structural heart disease are at higher risk in the face of the new coronavirus infection due to both advanced age and numerous comorbidities.

All variables must be taken into account when deciding whether a patient can wait (so as to minimize the risk of exposure to the virus) or their pathology must be addressed as soon as possible despite the pandemic, the risk of exposure, and the use of resources that are now scarce.

Any intervention that is unlikely to directly impact the clinical prognosis of the patient over the first two to three months after the procedure should be considered elective and be postponed.

This includes procedures such as left atrial appendage repair and closure of atrial septal defects and patent foramen ovales. Similarly, interventions for tricuspid regurgitation, which are currently under research, should be deferred whenever possible.

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Ideally, the rationale for deferring or conducting procedures should be discussed with patients and documented in their medical record.

In contrast, patients at imminent risk, with probably irreversible consequences (permanent damage to the target organ) and rapidly worsening symptoms that could provoke hospitalization, must be considered for an emergent or urgent procedure.

Most emergent cases will be inpatients already hospitalized whose condition has worsened despite treatment, who consequently require an intervention within hours or in a maximum of 2 days.

Read also: Cardiology in Times of Coronavirus: The Perfect Storm.

Patients with severe aortic stenosis with cardiogenic shock requiring inotropes or vasopressors, or patients with mitral regurgitation with refractory heart failure, even requiring an intra-aortic balloon pump, would constitute emergent cases.

Hospitalized patients who were stabilized but cannot be safely discharged without a procedure would constitute urgent cases. Additionally, patients with severe aortic stenosis admitted with refractory heart failure, or patients with severe aortic stenosis at high risk for decompensation in the next 15 days (such as those with recurrent syncope) would fall in the same category.

Outpatients can be classified based on the original assessment by the Heart Team, and their status can be updated through telemedicine.

Patients in Tier 1 (emergent/urgent) are defined as the highest risk cases requiring a procedure within the next 48 hours (emergent) or 1-2 weeks (urgent).

• Severe aortic stenosis classified as New York Heart Association (NYHA) functional class IV.
• Severe aortic stenosis with recurrent hospitalization, particularly in patients with a recent decline in left ventricular ejection fraction.
• Severe aortic stenosis with recurrent syncope.
• Severe aortic stenosis with recent chest pain.
• Severe aortic regurgitation due to bioprosthetic dysfunction with refractory heart failure.
• Severe mitral regurgitation with refractory heart failure requiring hospitalization.
• Severe aortic or mitral regurgitation in the setting of an acute coronary syndrome.

Patients in Tier 2 are defined as cases at high risk of clinical deterioration over the next 1-2 months. They require close weekly monitoring and the procedure must be conducted within 2 months.

• Severe aortic stenosis with rapidly progressive NYHA class III symptoms (especially in cases of ejection fraction deterioration or peak velocity >5 m/s).
• Severe aortic stenosis with recent decline in ejection fraction or new-onset atrial fibrillation (especially if peak velocity is >5 m/s).
• Severe mitral regurgitation with recent decline in ejection fraction or worsening NYHA class III symptoms despite optimal medical treatment.
• Severe tricuspid regurgitation with NYHA functional class IV symptoms and evidence of progressive damage to the target organ (e.g., worsening kidney failure).

Patients in Tier 3 (elective) are defined as subjects at lower risk, whose procedure can be postponed for 2 months or longer, if necessary.

• Severe aortic stenosis with NYHA functional class I or II, especially with preserved ejection fraction.
• Asymptomatic severe aortic stenosis.
• Severe mitral regurgitation with NYHA functional class I or II on optimal medical treatment.
• Severe tricuspid regurgitation with NYHA functional class I to III on optimal medical treatment.

Título original: The Restructuring of Structural Heart Disease Practice During The Covid-19 Pandemic.

Referencia: hristine J. Chung et al. Journal of the American College of Cardiology 2020, Journal Pre-proof. 

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