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‘Crisis-Driven’ Guidance on Structural Heart Disease in COVID-19

What your doctor is reading on Medscape.com:

APRIL 14, 2020 — Like so much else these days, the treatment of valvular and structural heart disease (SHD) has been turned on its ear. Elective procedures are canceled in many regions and, as hospitals become overwhelmed with COVID-19 patients, all but the most urgent care is postponed.

Patients in need of SHD interventions constitute a challenging group; many have conditions that may be life-threatening if treatment is inappropriately delayed. For others, the risk of intervention during a pandemic is greater than the risk of waiting. 

“It can be really hard to know exactly what is truly elective in cardiology. I think most of what we do, once a decision is made to do it, generally it’s felt that it’s better to get it done as soon as possible to prevent any complications from delay in treatment,” said Pinak B. Shah, MD, from Brigham & Women’s Hospital, Boston, Massachusetts.

Shah is the lead author of a consensus statement from the American College of Cardiology (ACC) and Society for Cardiovascular Angiography and Intervention (SCAI) on how to triage patients with SHD during COVID-19.

The document, published online April 6 in JACC: Cardiovascular Interventions, takes a broad approach to the triage of patients in need of SHD interventions during COVID-19

“As a ‘consensus statement,’ we took into consideration the variations in the severity of the epidemic around the country as well as the variability in resources of structural heart programs around the country,” Shah told theheart.org | Medscape Cardiology.

The statement provides a framework to guide decision-making about the appropriate timing for an intervention, despite the ongoing pandemic, and addresses the triage of patients needing transcatheter aortic valve replacement (TAVR) and percutaneous mitral valve repair, along with other SHD interventions.

Regarding TAVR, the writing group proposes timing for patients with symptomatic severe aortic stenosis (AS), minimally symptomatic severe to critical AS, and asymptomatic severe to critical AS. For those whose procedures are deferred, weekly telephone follow-up is recommended.

The authors also discuss managing infection risk in the cath lab, such as limiting transesophageal echocardiology to reduce potential for particulate aerosolization, and the conduct of clinical trials (ie, stop enrolling new patients and continue care for patients already enrolled and treated).

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