- All patients should receive COVID-19 screening prior to procedures
- Only personnel considered essential to all SHD related procedures should be a part of treatment staff in order to limit both infection and conserve PPE
- All procedures, including TAVR, should be performed with a minimalist approach in order to minimize hospital stay duration as much as possible

Ohio State University, Columbus

- This paper discusses development of a new schema more management and treatment for patients with structural heart disease (SHD) during the era of COVID-19
- The paper describes how patients with SHD may be at higher risk of infection and higher risk of poor outcome if infected with COVID-19 due to the nature of SHD itself as well as the possibility for patients with SHD to be comorbid with other diseases
- This paper goes on to detail a few different sections of information including how physicians who treat patients with SHD should transition toward telehealth, how specific SHD appointments should be rescheduled and reprioritized based off current condition, patient selection based off condition, the minimization of risk and optimization of SHD related procedures, as well as they eventual transition back to pre-COVID-19 era treatment of patients with SHD


Restructuring Structural Heart Disease Practice During the COVID-19 Pandemic

Chung, C. J., Nazif, T. M., Wolbinski, M., Hakemi, E., Lebehn, M., Brandwein, R., Rezende, C. P., Doolittle, J., Rabbani, L., Uriel, N., Schwartz, A., Biviano, A., Wan, E., Hathaway, L., Hahn, R., Khalique, O., Hamid, N., Ng, V., Patel, A., Vahl, T., … Kodali, S. K. (2020). Restructuring Structural Heart Disease Practice During the COVID-19 Pandemic: JACC Review Topic of the Week. Journal of the American College of Cardiology, 75(23), 2974–2983. https://doi.org/10.1016/j.jacc.2020.04.009

URL: https://pubmed.ncbi.nlm.nih.gov/32278716/


- The initial action toward limiting the spread off COVID-19 to patients with SHD was to reschedule appointments to later dates where there would hopefully be more control over the virus or to have patients perform a telehealth visit
- The limitations found due to this was the fact that statistically most SHD patients are much older and their technological ability was much lower and there was much more limited access to family or caregivers willing to assist with setting up telehealth equipment or software
- The primary solution to this was putting together an integrated team to assist with all the initial setup of telehealth software and equipment in order to streamline the appointment itself
- Additional to a phone call to talk to a patient to assess their condition, video calls may provide a good measure of condition
- For example over the phone a patient may not mention the true extent to their condition whether it be through lack of knowledge of terminology or inability to provide an adequate description of what’s going on, however, with a webcam a patient may be able to point the camera at a specific location and give a better visual description of their condition
- Another extremely important facet of cardiac care is that physicians must provide clear instructions to patients on how to properly care for their condition at home in order to limit the possibility of a hospital visit as much as possible


Transition Toward Telehealth by Physicians who Treat SHD

- Most interventions scheduled with patients in the short term that are considered elective should most likely be postponed in order to limit infection risk
- However, interventions which are to be performed to assess a possible life-threatening symptom or condition must still occur and should be carried out accordingly
- These various situations must be assessed on a case by case basis in order to make sure each patient is receiving the proper level of care based on their condition
- This paper provides a graphic, Figure 1, specific to SHD which describes various patient conditions and their severity in order to provide a clearer picture on what visits could be considered elective versus essential
- However, Figure 1 is not based upon a linear scale and is heavily dependent upon other risk factors at a specific facility such as the occupancy of COVID-19 positive patients within the ICU, the paper implies that with low COVID-19 ICU occupancy, urgent procedures should most likely be performed. But if there is high COVID-19 ICU occupancy, urgent procedures should be more heavily screened based off a risk/benefit profile to assess if putting the patient in danger during recovery outweighs their current circumstances.


Rescheduling and Reprioritizing Patient Visits Based Off Current Condition and Relative Patient Risk

- In order to establish fair and consistent guidelines for patient care with limited resources, resources must allocated in order to maximize number of lives saved, rewarding instrumental value, and prioritizing those who are considered the worst off
- This may be done by breaking up a patient’s condition into its core components and creating a diagram on the Central Illustration to assess how a patients falls in the resource allocation perspective
- By utilizing the Central Illustration, patients who create the largest polygons are associated with the most risk and therefore should be denoted the most care resources as in theory their condition is the worst
- This distribution of resources must be assessed at all facets of a patient’s care including surgery whereas an example a procedure such as a valve replacement shouldn’t be performed if a patient is considered low risk with severe aortic stenosis, but this patient should instead be considered for a trans catheter aortic valve replacement (TAVR) which is considered more minimally invasive and can accelerate recovery time


Patient Selection Based off Condition and Environmental Restraints

Minimizing Risk and Optimizing Procedures for SHD During the COVID-19 Era

- Until a vaccine is readily available and widely adopted, a transition back to normalcy cannot be started
- As outpatient facilities begin to reopen to a fuller extent and more in person appointments become common practice, the guidelines outlined in Figure 1 should still be followed, however, lower risk individuals may be seen in person
- An example of the extent of the reopening includes more intervention with patients who are considered in the Tier 2 risk in Figure 1 as they present possible issues down the line which could emerge later with more in person intervention and examination
- Additionally, while more elective surgeries may be performed, there will be vast competition for these types of surgeries everywhere as all surgical departments will be providing more elective procedures


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