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ORIGINAL ARTICLE
Year : 2021 | Volume
: 10
| Issue : 4 | Page : 112-114
Adult congenital and structural interventions in coronavirus disease 2019 era: Report from an Iranian tertiary cardiovascular center
Sedigheh Saedi1, Ata Firouzi1, Abdolvahab Baradaran2
1 Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Cardiac Primary Prevention Research Center, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
Correspondence Address:
Dr. Sedigheh Saedi
Rajaie Cardiovascular Medical and Research Center, Vali-asr Ave, Adjacent to Mellat Park, Tehran
Iran
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/rcm.rcm_46_21
Background: Iran is one of the countries hit hard and early by the corona virus disease 2019 (COVID-19) outbreak. Interventions for congenital and structural heart disease came to a halt in the initial part the year 2020, however as the pandemic seemed no closer to an end there was a mandate for elective catheterization procedures to be slowly and cautiously resumed. Aims and Objectives: In the present report we discuss the challenges we faced and the experiences earned as a cardiovascular tertiary center in the field of adult congenital and structural interventions in the COVID era. Material and Methods: Adult congenital and structural interventions were resumed in May 2020 with implementing strict screening protocols regulated by our institutional COVID committee. Patients were closely monitored for developing COVID-19 symptoms in hospital and two weeks following discharge. Results: In the regular review performed by the COVID committee there was no increase in new cases of the disease related to the interventional procedures and related admission. Conclusion: As the fate of pandemic remains unforeseeable, structural and congenital interventions need to be resumed in a sustainable fashion and with an instituted system of patient protection. The workflow might slow down during disease peaks with a catch-up in more stable disease periods.
Keywords: Cardiac catheterization, congenital heart disease, coronavirus disease 2019, structural heart disease
The first officially confirmed cases of coronavirus disease 2019 (COVID-19) in Iran were reported at the end of February 2020. Since then, over 6 million people have been infected and over 100,000 have died.[1] At the beginning of the pandemic, cardiac catheterization laboratory (cath lab) procedures became limited to emergent coronary interventions, and all the nonemergent procedures were postponed in March 2020. The outbreak dictated a state of standstill to elective interventions and surgeries, including procedures for adult congenital and structural heart disease. As COVID-19 continued through 2020, we faced many patients with delayed interventions, and the end of the pandemic seemed even more obscure. We, therefore, had no choice but to develop a practical protocol for the management of elective patients. In the present report, we discuss our strategies and experiences in adult congenital and structural interventions during the COVID era.
MethodsOur institutional COVID committee started regular meetings in March 2020. The committee consists of attending physicians and experts from every hospital discipline, including cardiologists, radiologists, intensive care unit, infectious disease specialists, and the administrative board of the hospital. Our hospital is a tertiary referral center for cardiovascular disease and is not assigned as a first-line receiving center for COVID patients; however, as there is an overlap between the respiratory symptoms of COVID and cardiac patients, many infected patients present to our emergency department. We dedicated isolation wards to patients with cardiovascular conditions diagnosed with infection at admission or during the hospital stay. In May 2020, there was a period of relative stability in the emergence of new COVID cases and the committee agreed on the resumption of admission of patients requiring elective procedures including adult congenital and structural heart disease patients in limited numbers and after full preadmission screening for infection. The screening protocol consisted of an initial clinic visit and evaluation by an infectious disease specialist. A detailed history of any close contact with suspected or confirmed COVID cases would be taken. Laboratory tests including complete blood count, C-reactive protein (CRP) and chest computed tomography (CT) were performed .In patients with suspicious results the procedure was canceled. CRP levels >6 mg/l, lymphopenia with the definition of lymphocyte count ≤1100μl, and CT findings of bilateral and peripheral ground-glass and consolidative pulmonary opacities were considered abnormal. The patients were required to have a negative reverse transcription–polymerase chain reaction (PCR) test result for COVID-19 issued in the past 48 h. Patients were provided with surgical masks and were notified and educated about proper social distancing protocols that were strictly executed during their course of hospital stay. We pursued a no-visitor policy, and updates were given to the family members by phone. The cath lab personnel and physicians were provided with full personal protection equipment. The patients received optimal quality but expedited treatment to minimize their stay in the hospital. We frequently monitored the patients for any signs or symptoms regarding COVID-19 infection. The ethics committee of the Iran University of Medical Sciences approved the study protocol (1400.284). On discharge, the patients were advised to report any new symptoms compatible with COVID-19 to the hospital. Categorical and normally distributed quantitative variables were recorded as numbers (percentages) and mean ± SD, respectively. P < 0.05 were considered statistically significant.
ResultsIn the regular review performed by the COVID committee, there was no increase in new cases of the disease related to the cath lab procedures. It was then decided that the routine chest CT be omitted from the screening protocol if deemed unnecessary by the infectious disease specialist. We began performing adult congenital and structural interventions in May 2020 and over the second half of the year 2020, the number of the mentioned interventions gradually increased and occasionally approached that of the non-COVID era. The mean age of patients undergoing procedures was 43 ± 12 years and 64% were female. There were rapid upsurges in the number of new cases and the death toll in June 2020 and November 2020, with the latter being the gravest peak since the start of the outbreak. The interventions slowed down during these periods with a catch-up in more stable months. [Table 1] and [Figure 1] depict the comparative number of interventions in the COVID era and the same period in 2019. We performed follow-up evaluation and documented that none of the patients undergoing adult congenital or structural procedures contracted COVID-19 in the course of their hospital stay. No patient showed signs of infection or had positive COVID PCR in the 14 days following hospital discharge.
Table 1: Comparison of the volume and type of congenital and structural interventions in precoronavirus disease and coronavirus disease outbreak
Figure 1: Changes in congenital and structural procedures during COVID pandemic, ASD: Atrial septal defect, PMBV: Percutaneous mitral balloon valvuloplasty, VSD: Ventricular septal defect, PDA: Patent ductus arteriosus, PBAV: Percutaneous balloon aortic valvuloplasty, TAVI: Transcatheter aortic valve implantation, PFO: Patent foramen ovale, CAF: Coronary artery fistulae, PPV: Percutaneous balloon pulmonary valvuloplasty, PL: Paravalvular leakage device closure, and ROSV: Device closure for ruptured sinus of Valsalva Discussion There are multiple challenges in the path of resuming routine cath lab activities for structural and congenital interventions during the COVID-19 pandemic. Patients should be offered high standard and swift treatment with minimum hospital stay. Physicians face the accumulation of cases that were postponed during the initial months while precautions to limit the COVID transmission decelerate the management process. There are occasions with incapacitating reduction in the number of staff due to disease exposure or sick leaves. In teaching hospitals such as our institution, an important issue encountered by the attending physicians is fulfilling the training requirements of the educational curricula of the residents and subspecialty fellows and at the same time considering the need for performing the interventions with a higher pace in expert hands and limit the number of individuals present during each procedure.[2],[3]
Many patients defer hospital admission for fear of contracting the disease, whereas many others become overly anxious and concerned as their procedure is delayed leading to unnecessary emergency room visits. Follow-up visits and recommended postprocedural echocardiographic surveillance also pose a serious challenge in the COVID era as there are travel restrictions across the country, curtailed outpatient clinic admission capacity, or patients' own fear of showing up at the hospital.[2],[4],[5],[6],[7]
Despite all the difficulties, as the end of the pandemic and mass vaccination results are uncertain, there is an obligation for the resumption of adult congenital and structural interventions. We had no congenital and structural interventions performed between March 2020 and May 2020, after which the procedures were cautiously resumed with limited and prioritized patients. Since then with improved availability of COVID-19 testing, thorough screening, and meticulous application of public health protocols, we have been able to accomplish many procedures with the volumes approaching pre-COVID numbers in some months. We attempt to compensate for the educational shortfalls by virtual meetings, webinars, and simulation methods. For patient follow-up, eligible local physicians were contacted and instructed to communicate any problems directly to the treating physician. Telephone consults are given to patients living in remote areas and outpatient clinic hours were also extended.
Our experience demonstrates that congenital and structural interventions can be safely and effectively performed during COVID with the supervised and monitored implementation of health protocols; however, every institution has to define their own local guidelines and protocols taking into account their resources and shortages.
ConclusionCOVID-19 has the potential to spread exponentially, and vaccination results are not fully predictable. Structural and congenital interventions need to be resumed in a sustainable fashion and with an instituted system of detailed patient screening. The workflow might slow down during disease peaks, and there should be a catch-up scheme for more stable disease periods.
Ethical clearance
Ethics committee of Rajaei Cardiovascular Medical Research Center, Tehran, Iran approved of the study protocol.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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