Performing Structural Heart Disease Interventions During the COVID-19 Pandemic: But What Are the Downsides?

We read with interest the American College of Cardiology and Society for Cardiovascular Angiography and Interventions consensus statement on triage considerations for patients referred for structural heart disease (SHD) intervention during the current coronavirus disease 2019 (COVID-19) pandemic by Shah et al. (1). The paper provides useful guidance regarding triage and timing of interventions for patients awaiting SHD treatment during this global crisis. However, we believe that the possible downsides of performing (high-risk) cardiovascular interventions during this period require additional discussion. These considerations should be more explicitly incorporated in any framework addressing interventions during the COVID-19 pandemic.

It is clear that time is not a luxury most patients with symptomatic cardiovascular diseases can afford, especially regarding SHD. For inpatients who cannot be discharged due to medical reasons, it is rational to perform necessary interventions during the COVID-19 pandemic, analogous to recommendations from the consensus statement (1). Conversely, for outpatients, risks for sudden cardiac death or irreversible cardiac deterioration while awaiting intervention should be weighed against the risks of nosocomial COVID-19 exposure and associated morbidity and mortality. Although the chances of nosocomial COVID-19 transmission in this setting are largely unknown and are being investigated (NCT04290780), the possibility is factual and well reported (2,3). Furthermore, the phenomenon of asymptomatic carriers of COVID-19 has become increasingly important, inciting an absolute (but still unmeasurable) risk that COVID-19 positive patients, albeit without any symptoms, will undergo high-risk cardiovascular interventions. Although it is uncertain how COVID-19 will influence the periprocedural period, these cardiovascular patients commonly share similar risk factors (i.e., elderly patients with pre-existing concurrent cerebrovascular conditions, diabetes, or chronic kidney diseases) to patients who have the highest risks for mortality after being hospitalized for COVID-19 pneumonia (4).

Unfortunately, there are currently insufficient data available to properly guide us in this difficult balancing act. Updated regional and national epidemiologic data on COVID-19 prevalence are sorely needed. Moreover, we eagerly await further reports with case series detailing selection criteria, outcome data, and risks of nosocomial COVID-19 transmission for (out)patients undergoing cardiovascular interventions during this pandemic. Also, the expansion and improvement of testing to identify asymptomatic COVID-19 carriers will be crucial for optimal case selection. Until then, the dilemma of choosing the lesser evil will remain a challenge for the clinician and the patient on a daily basis.