Negative impact of coronavirus on interventional cardiology fellows' training: Let's limit collateral damage of the pandemic.

With over 88 million cases and 2 million deaths as of January 10, 2021, the coronavirus disease 2019 (COVID‐19) is having a catastrophic impact on most healthcare systems worldwide. This unprecedented pandemic has also caused a dramatic reduction in nonemergent clinical and surgical activities, including interventional cardiology procedures. In fact, with the overarching goals to preserve intensive care unit beds, anesthesiologists, ventilators and personal protective equipment, and to avoid unnecessary patient exposure to nosocomial infectious risk, many hospitals have been deferring nonurgent operations, including those in subjects with stable coronary artery disease and structural heart disease. Moreover, during the first wave of the COVID‐19 pandemic, a striking reduction (−48%) in hospital admissions for acute coronary syndromes has been observed, both for ST‐elevation (−26%) and non‐ST‐elevation (−65%) myocardial infarction. Changes in ST‐elevation myocardial infarction protocols with a more frequent use of thrombolysis have also been reported, particularly in non‐Western countries. For these reasons, procedure volumes of most catheterization laboratories around the world significantly decreased, thereby reducing the caseload of interventional cardiology fellows.

In this issue, Gupta et al report the results of a survey performed at 14 interventional cardiology training hospitals in the New York metropolitan area, which has long been the epicenter of the COVID‐19 pandemic in North America. Not surprisingly, all programs reported a significant decrease in their catheterization laboratory procedural volumes, with one out of five program directors expecting their fellows to perform <250 percutaneous coronary interventions during their year of training. These results were caused not only by the reduction in interventional procedures, but also by the reallocation of cardiology fellows to COVID‐19 units to help preventing many hospitals from collapsing under the endless tide of patients admitted with respiratory distress. The findings of this survey are similar to another European experience reporting a drop in catheterization laboratory activities over 50% in two thirds of centers, with half of interventional cardiology fellows revealing a reduction of the involvement in the procedures by the tutor in order to become more time‐efficient and to spare personal protective equipment in times of resources constraints.

Interestingly, both program directors and interventional cardiology trainees of advanced second year structural heart intervention fellowship were less concerned by the impact of COVID‐19 pandemic on the ability to achieve adequate technical skills. These results are quite surprising, considering European data showing a significant drop (79% reduction) in structural heart interventions volume during the first wave of the pandemic, which was particularly pronounced for percutaneous mitral valve repair, left atrial appendage occlusion and patent foramen ovale closure (over 90% reduction) as compared to transcatheter aortic valve replacement (TAVR) (69% reduction). Advanced interventional cardiology fellows might be more confident because they have already completed a 12 month of interventional training, but also considering that a significant proportion of structural heart intervention skills lay in preprocedural imaging and heart‐team discussion (less impacted by the pandemic), and technical procedural aspects might be perceived as secondary. Moreover, while other structural heart interventions are more likely to be postponed (as they require intubation and transesophageal echocardiography, which pose higher risk of COVID‐19 infection for the structural heart disease team and utilize constrained resources), the pandemic (together with the extension of TAVR indications to low‐risk patients) might have the paradoxical effect of increasing the number of TAVR, which is less resource‐consuming as compared to surgical aortic valve replacement. In fact, the majority of TAVR procedures can be safely performed with a minimalist percutaneous approach under conscious sedation, frequently without need for intensive care unit recovery and with next day hospital discharge.

The pandemic led training programs to evolve by including a more extensive use of telemedicine, web‐conferences and simulation workshops, but none of these can substitute real‐life clinical practice in the catheterization laboratory. As the health crisis endures, it is our duty to find ways to ensure adequate patient care but also to reduce the collateral damage of the pandemic in terms of negative impact on education of future interventional cardiologists generations. To this regard, training hospitals need to restructure their practice. Implementation of formal COVID‐19 protocols with extensive use of swabs and serological testing before admission are needed to minimize the risk of in‐hospital outbreaks while ensuring appropriate and timely treatment of patients. Structural heart intervention programs will need to be reorganized to minimize hospital stay (optimizing preprocedural, periprocedural, and postprocedural care), preferably without intensive care unit admission. Less‐invasive imaging tools such as intracardiac echocardiography or micro‐transesophageal echocardiography might be used in order to reduce the need for anesthesiologists' involvement thus minimizing infrastructure requirements.

As the authors pointed out in their article, despite the negative impact on procedural volumes, this unprecedented crisis provided fellows the chance to discover invaluable skills to become better doctors, such as cooperation, adaptation and, most importantly, empathy.

“A good physician treats the disease, the great physician treats the patient who has the disease”—Dr. William Osler.

CONFLICT OF INTEREST

The authors declare no conflict of interest.