In the early months of the COVID-19 pandemic, states and cardiovascular societies recommended postponing all nonemergent cardiac procedures including, in some cases, transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS). Resource conservations (hospital beds, ICU beds and PPE) as well as staff availability were major concerns. This recommendation also aimed to reduce potential nosocomial infection in patients at high risk for COVID-19-related mortality such as those with advanced age or comorbid conditions. Since these characteristics are also common in symptomatic severe aortic stenosis patients, the COVID-19 pandemic posed significant challenges to managing a group of patients with a mortality rate in excess of 3% per month when left untreated.
The TAVR procedure has evolved rapidly in recent years, becoming both more accessible and more streamlined. The COVID-19 pandemic has introduced additional parameters to consider when performing TAVR, forcing many heart teams to accelerate the process of innovation to meet the demand for safe, effective treatment of aortic stenosis. AMITA Health has long been a leader in bringing the latest in heart valve research into the clinical setting. This expertise has made the multidisciplinary heart valve/TAVR team at AMITA uniquely suited to meet the challenges of the COVID-19 landscape while also continuing to expand upon the patient-centered approach taken before the pandemic.
Aortic stenosis in the era of COVID-19
The use of TAVR in patients with aortic stenosis has grown significantly in recent years. In the past, only those at high risk of complications during surgical aortic valve replacement (SAVR) were considered for TAVR. After first being approved for intermediate risk patients, in 2019, the indication was expanded to include patients in all surgical risk groups. Compared with patients undergoing SAVR, patients receiving TAVR show faster recovery times and reduced hospital length of stay.
Numerous studies have shown that extended postponement of AVR procedures increases incidence of cardiac events and increases mortality in patients with aortic stenosis (refrence 1).
Taken into account the need to continue treatment of patients with aortic stenosis in the face of the COVID-19 pandemic, , cardiovascular societies have urged heart centers to modify pre-procedural, intraprocedural, and post-procedural elements in order to better manage the safety and resource conservation concerns raised by the COVID-19 pandemic.
For example, the American Heart Association has put forth several recommendations, including minimizing time spent in the hospital, employing the use of telehealth for preprocedural visits, and performing catheterization in a negative pressure space (refrence 2).
AMITA Health: A safer, minimalist approach to valve replacement
Patients with symptomatic aortic stenosis referred to the AMITA Alexian Heart & Vascular Institute undergo a focused workup to determine the approach most suited to their situation. This includes consultation with an interventional cardiologist and cardiothoracic surgeon. To limit the amount of hospital exposure, these visits are scheduled for the same day as the CT angiography. Any other follow up visits with the heart valve/TAVR team are performed virtually via telehealth.
If the patient is deemed an appropriate candidate for TAVR, the procedure is scheduled within 1-2 weeks and performed in an industry-leading hybrid catheterization laboratory, equipped with a negative pressure antechamber and full surgical support. Due to the design of the laboratory and to the protocols being used, the number of ancillary staff can be reduced without impacting the team’s ability to address complications should they arise.
A faster road to recovery
For each day spent in the hospital, an elderly patient can lose as much as 10% of their strength. Accordingly, the AMITA Health Heart & Vascular Institute has worked to minimize post-TAVR recovery time in patients with symptomatic aortic stenosis in emergent, urgent, and elective cases. Early ambulation and short length of stay reduce patient deconditioning and the potential for exposure to nosocomial infections. In the era of COVID-19, this also ensures that resources are conserved and better allocated. In 90% of cases, patients bypass the intensive care unit and are discharged within 24 hours.
The heart valve/TAVR team has also worked to develop a recovery area designed for post-TAVR patients so that they are isolated from the general intensive care unit population. The staff in this area is laser focused on safe and rapid ambulation in order to engage patients in the active recovery process. Typically, those recovering from TAVR are able to be discharged to the home as early as eight hours post-procedurally. Due to constraints of COVID, the AMITA Alexian Brothers team was the first in the state of Illinois and one of the first in the nation to initiate a Same Day discharge Program for highly selected TAVR patients.
References
- Ro R, Khera S, Tang GHL, et al. Characteristics and Outcomes of Patients Deferred for Transcatheter Aortic Valve Replacement Because of COVID-19. JAMA Netw Open. 2020;3(9):e2019801. Published 2020 Sep 1. doi:10.1001/jamanetworkopen.2020.19801
- Mentias A, Jneid H. Transcatheter Aortic Valve Replacement in the Coronavirus Disease 2019 (COVID-19) Era. J Am Heart Assoc. 2020;9(11):e017121. doi:10.1161/JAHA.120.017121
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