Balancing Service and Safety: Cardiovascular Medicine Divisional Response to the COVID-19 Pandemic.

The novel coronavirus disease-2019 (COVID-19) outbreak has rapidly escalated into a global pandemic. Experience from recent epidemics, as well as familiarity with annual influenza infections, demonstrates that cardiovascular complications of respiratory viral infections are common, including acute myocardial infarction, myocarditis, and development or exacerbation of congestive heart failure (1,2). Furthermore, emerging data from COVID-19 epicenters demonstrates a high burden of comorbid cardiovascular disease among patients with the most severe manifestations (3). Thus, each hospital, and specifically, each cardiovascular disease division, requires a coordinated plan that balances quality care to COVID-positive patients and persons under investigation (PUI) with the safety of health care workers (HCW), all while maintaining consistent access to care for patients without infection.

Inpatient Consultation Services

Inpatient consultations on PUI/COVID-positive patients now emphasize “e-consultations” except in specific clinical scenarios (Table 1) or if direct patient examination is determined to be necessary by the attending cardiologist. Tools to minimize use of personal protective equipment (PPE) and multiple patient interactions include Bluetooth-capable stethoscopes and review of point-of-care ultrasound images obtained by the primary team. Close communication with the requesting teams continues to be prioritized to provide adequate and succinct clinical guidance. All PUIs who have tested negative for COVID-19 are examined fully before referral for invasive procedures. Our service is modeled after previously published “e-consultation” workflow recommendations in “peacetime” prior to the SARS-CoV-2 outbreak (4).

Table 1

Consult Service Indications for In-Person Physical Examination

Acute coronary syndromes with hemodynamic instability or STEMI where systemic thrombolysis or primary angioplasty is considered

Decompensated heart failure with signs of hypoperfusion, pulmonary edema, and/or requiring inotropic support

Suspected cardiac tamponade

Cardiac arrhythmias failing medical treatment

STEMI = ST-segment elevation myocardial infarction.

Acute Coronary Syndrome and The Cardiac Catheterization Laboratory

A significant proportion of patients with COVID-19, particularly among those who develop critical illness, exhibit some degree of myocardial injury characterized by elevation in serum troponin concentrations (5). Proper case selection for the cardiac catheterization laboratory (CCL) is complicated by multiple proposed models of cardiac injury in COVID-19, including myocarditis masquerading as ST-segment elevation myocardial infarction, angiotensin-converting enzyme-2 mediated cell injury, cytokine storm, microvascular damage, and hypoxia-related injury (6). Joint recommendations from the Interventional Council of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions provide guidance on operations in the CCL during the COVID-19 pandemic (7).

Our CCL developed a phased approach based on the local prevalence of COVID-19 and pretest probability of infection in the absence of widespread testing (Figure 1). In phase 1, we developed protocols on the approach to ST-segment elevation myocardial infarction in a PUI/COVID-positive patient (Figure 2), rescheduled elective cases (Table 2), performed extensive staff PPE training, and equipped a dedicated laboratory with a high-efficiency particulate air filter and anteroom to create a negative pressure equivalent for an anticipated surge in cases. In phase 2, we implemented these processes, and all emergent cases were treated as PUIs. As we approach phase 3, our processes continue to undergo iterative improvements and all cases coming to the CCL will be considered PUIs. All patients referred to the laboratory arrive wearing a facemask to mitigate droplet spread and detailed donning and doffing steps customized to our laboratory’s training are mounted for review in the anteroom. Finally, close coordination with units caring for post-catheterization patients is necessary to ensure comfort in biocontainment units with management of active cardiac conditions.

Figure 1

Phased Approach to Cardiac Catheterization Laboratory COVID-19 Response

COVID = coronavirus disease-2019; CPR = cardiopulmonary resuscitation; ER = emergency room; HEPA = high-efficiency particulate air; LUCAS = Lund University Cardiopulmonary Assist System; NSTEMI = non-ST-segment elevation myocardial infarction; PAPR = powered air-purifying respirator; PCI = percutaneous coronary intervention; PPE = personal protection equipment; PUI = persons under investigation; STEMI = ST-segment elevation myocardial infarction.

Figure 2

Approach to STEMI in the PUI/COVID-Positive Patient

EKG = electrocardiogram; HCW = health care worker; LV = left ventricle; other abbreviations as in Figure 1.

Table 2

Elective Catheterization Case Categories to be Postponed During Pandemic

Outpatient right heart catheterization (excluding heart transplants under 6 months)

Left heart catheterization for stable coronary artery disease

Chronic total occlusion

Atrial septal defect closure

Nonurgent transcatheter aortic valve replacement

With thoughtful selection of patients for CCL procedures and meticulous adherence to donning and doffing steps, coronary angiography can be pursued with significant mitigation of HCW risk during the pandemic.

Electrophysiology

All elective, nonurgent catheter ablation and device procedures are being deferred in accordance with Heart Rhythm Society recommendations (8), except for urgent and emergent cases listed in Table 3. Importantly, because most electrophysiology laboratories have either neutral or positive pressure air flow, we recommend either temporarily converting them to negative pressure rooms if feasible or performing these procedures in a hybrid operating room with negative pressure air flow. For inpatient PUI or COVID-positive patients, we perform e-consultations using electronic medical record resources such as clinical charts, review of electrocardiograms and cardiac imaging studies, and remote telemetry review. For perioperative device programming we favor magnet use by the surgical team whenever appropriate to minimize double exposure to the electrophysiology team from programming before and after surgery. Our exceptions include patients with implantable cardioverter defibrillator who are pacemaker-dependent and are undergoing surgery above the pelvis, which includes the use of electrocautery, because magnet placement will only inhibit tachycardia therapies but will not pace asynchronously.

Table 3

Urgent Electrophysiology Procedures to Proceed With During Pandemic

Proceed With Following Ablation Procedures	Proceed With Following Device Procedures
VT storm∗	Infected CIED
Pre-excited atrial fibrillation with hemodynamic compromise	Devices at ERI or EOS
Supraventricular tachycardia nonresponsive to medical therapy or cardioversion, with hemodynamic instability	Pacemaker for advanced or complete heart block, or bradycardia (evidenced by severe sinus node dysfunction) causing hemodynamic compromise†
	Device- or lead-related malfunction posing immediate risk to the patient (lead fracture, undersensing issues, manufacturer recall posing clinical risk)

CIED = cardiac implantable electronic devices; EOS = end of service; ERI = elective replacement indicator; VT = ventricular tachycardia.

VT storm that has failed medical treatment including at least 2 antiarrhythmic drugs (including propranolol), treatment of underlying reversible condition if present (QTc prolongation due to ischemia, medications, or metabolic/electrolyte imbalance), general anesthesia, and left stellate ganglion block (if available).

Not reversible or fails to respond to chronotropic drugs such as isoproterenol, dopamine, and/or scopolamine, and temporary pacing cannot be safely maintained in an intensive care setting. In this scenario a screw-in active fixation lead connected to an externalized generator or an active fixation temporary pacing lead may be considered depending on the patient’s clinical condition and could be performed in the intensive care setting under fluoroscopic guidance (if available) or in an operating room with negative airflow capabilities and fluoroscopy.

Multiple potential COVID-19 therapies, including chloroquine, hydroxychloroquine, azithromycin, ritonavir, and lopinavir, are known to prolong the QTc interval. We recommend extreme caution when initiating hydroxychloroquine, which is currently the QT-prolonging therapy most commonly being used at our center, in men with a QTc >450 ms, women with a QTc >470 ms, and patients already on QTc-prolonging medications. Routine monitoring of the QT interval is also necessary. Finally, some of the cardiac complications of COVID-19 infection, including acute coronary syndromes and myocarditis, may present with life-threatening ventricular arrhythmias. In these patients we strongly recommend against the use of Class III anti-arrhythmic drugs due to their QTc-prolonging effect.

Echocardiography

The American Society of Echocardiography has published recent guidelines for echocardiography use during the COVID-19 pandemic, indicating further triaging of appropriate use criteria is necessary to deploy resources safely (9). Our division developed indications for STAT and routine echocardiography requests in PUI/COVID-positive patients, as outlined in Figure 3. Performance of transesophageal echocardiogram (TEE) poses an added risk to providers given aerosolization of the virus during intubation. Our approach to STAT and routine TEE is outlined in Figure 4. Aside from acute valvular pathology requiring intervention, routine TEE requests are deferred for PUI patients until COVID testing is completed and for COVID-positive patients until clinical recovery and documentation of viral clearance. Additionally, all TEE procedures, even for non-PUI/COVID patients, are consolidated into a single operating room with universal N95 or powered air-purifying respirator protection, assuming widespread community infection rates. Finally, to prioritize sonographer safety, we implemented an image acquisition protocol (Figure 5) for PUI/COVID-positive patients, which reduces time spent at the bedside to 10 min while still obtaining the vast majority of images needed to provide clinical guidance.

Figure 3

Policies for STAT and Routine Echocardiography in PUI/COVID-Positive Patients

CT = computed tomography; ECMO = extracorporeal membrane oxygenation; other abbreviations as in Figures 1 and 2.

Figure 4

Policies for STAT and Routine TEE in PUI/COVID-Positive Patients

TEE = transesophageal echocardiogram; other abbreviations as in Figures 1 and 3.

Figure 5

Focused PUI/COVID-Positive Transthoracic Echocardiogram Protocol

TAPSE = tricuspid annular plane systolic excursion; other abbreviations as in Figures 1 and 3.

Advanced Heart Failure And Transplantation

Individuals with advanced heart failure, orthotopic heart transplants, or left ventricular assist devices (LVAD) represent a highly vulnerable subset of the cardiac patient population. In accordance with recent guidance from the International Society for Heart Lung Transplantation (10), we developed protocols to protect these patients while maintaining their need for close, high-quality care. In critically ill patients with urgent indications for advanced heart failure therapies (Interagency Registry for Mechanically Assisted Circulatory Support profiles 1 to 3), we prefer implanting a LVAD as a bridge-to-transplantation over proceeding directly to transplantation. In patients who are not appropriate candidates for LVAD therapy, we consider heart transplantation based on our algorithm described in Figure 6. Patients who are up to 6 months post-transplantation continue to undergo surveillance biopsies, echocardiograms, and ambulatory visits as previously scheduled. For inpatient post-transplantation patients and patients with LVADs, we request e-consultations whenever possible.

Figure 6

Algorithm for Heart Transplantation in Patients Who Are Not Appropriate LVAD Candidates

LVAD = left ventricular assist device; PCR = polymerase chain reaction; other abbreviations as in Figure 1.

Ambulatory Care

The pandemic creates an unprecedented challenge to our patients’ need for reliable longitudinal care. To prevent further community infectious spread, we cancelled in-person ambulatory encounters for nonurgent patients. Routine well visits were rescheduled, all necessary medication refills were provided, and patients were instructed to monitor cardiac symptoms and report changes in clinical status to their cardiologist. A telemedicine service was rapidly brought online to continue follow-up appointments via home or office settings. All stress test orders were discussed with the referring physician to determine level of clinical suspicion and acuity of need.

In the advanced heart failure practice, routine in-person LVAD practice visits were rescheduled with a focus on telemedicine and home international normalized ratio checks, coupled with the use of remote monitoring digital platforms. Data gathered includes symptoms, vital signs, LVAD parameters, and changes in thoracic impedance via remote implantable cardioverter defibrillator interrogation. Telemedicine visits and telephone monitoring are also offered in lieu of routine visits to patients with pulmonary hypertension based on clinical complexity.

Our Heart Failure Readmission Initiative and infusion clinic remain operational, providing a critical link between patients transitioning from the inpatient to ambulatory setting to ease the burden on the emergency room and inpatient services. Our workflow is detailed in Figure 7, with additional infusion chairs identified as part of our contingency planning.

Figure 7

HFRI and Infusion Clinic Workflow

HFRI = Heart Failure Readmission Initiative; IV = intravenous.

Remote monitoring is used for electrophysiology clinic device checks, with patients triaged to present for evaluation if they develop concerning arrhythmias, heart failure alerts, or device-related issues.

Maintenance of Service Lines and In-Patient Services

Fellows continue to staff essential services including the Advanced Heart Failure Service, the Primary Cardiology Service, and inpatient consults. We reduced the number of fellows on the cardiac catheterization and echocardiography (including TEE) rotations. All other fellows are assigned home study or support roles to minimize the overall risk of exposure and to maintain a backup pool. All pregnant trainees are excused from direct interactions with PUI/COVID-positive patients due to the lack of long-term outcomes data in this population. We made similar decisions among faculty members, and some support roles, such as backup echo reading, are performed from home. Numbers of in-house echocardiography sonographers and ambulatory nurses were reduced, and administrators were moved to telework.

Our inpatient Advanced Heart Failure Service and Primary Cardiology Service implement social distancing of 6 feet or greater between providers and patients as well as among team members, and only the attending enters the room during rounds. Strict handwashing is reinforced and universal donning of surgical masks, face-shields, and short sleeves by all providers is required. The hospital’s transfer center, the cardiology attending on record, and the charge nurses are involved in every out-of-hospital transfer or direct admission from home to universally screen patients for symptoms. Furthermore, we perform all handovers of patient care between teams via teleconference to further minimize exposure.

Research and Education

All in-person meetings and educational conferences were canceled and moved to virtual formats, including Skype and Zoom, to continue the division’s educational mission, maintain communication, and foster camaraderie. A cloud-based COVID-19 Policies and Education folder was created and distributed to all members of the division, including physicians, nurses, technicians, and administrators. The compendium serves as the official repository for newly created guidelines on each service line and provides up-to-date literature to guide clinical care. We also created a clinical research database directory of COVID-positive patients and are laying groundwork to create a serum and plasma-based biorepository to study COVID-19's association with cardiovascular disease.

Conclusions

The COVID-19 outbreak has quickly created a massive challenge to health care systems across the world. Recent lessons from COVID-19 hotspots include prioritizing safety of HCWs, minimizing nonurgent encounters to reduce infection rates, preserving capacity for anticipated surges, creating safe workflows to address the needs of PUI/COVID-positive patients, and finding creative solutions to maintain high-quality care for non-COVID patients. Anticipated challenges include limited digital access for patients with lower socioeconomic status, possible reduction in the workforce if HCWs are infected, and interruptions to cardiovascular fellow education and caseload volume for future credentialing. Furthermore, it remains to be seen whether a consistent level of patient care can be maintained in a predominantly remote setting. Outcomes data will be necessary to assess the efficacy of our approach in maintaining patient welfare while reducing personnel exposure. We hope this algorithm-based methodology may be expeditiously applied in cardiac centers worldwide, but unique resource allocation, available technology, and patient demographics may dictate adaptations necessary to suit each center’s circumstances.