COVID-19: Impact on cardiology procedural services

Take Home Messages
COVID-19 has led to a major re-structuring of cardiac services within the UK (i.e. postponement of non-urgent elective procedures and rationalisation of acute services). The major British cardiac societies have provided guidance which has helped inform a timely update of local hospital protocols and pathways. Health care workers are advised to wear appropriate personal protective equipment to minimise the risk of viral transmission, with particular care during aerosol generating procedures. For Cardiology these are defined as “any procedure requiring or likely to require resuscitation for cardiac arrest involving cardiopulmonary resuscitation ± intubation and to transoesophageal echocardiography.” Clinicians should be aware that changes to cardiology services due to COVID-19 may have adverse consequences for patients (e.g. delayed diagnosis and treatment resulting in worse outcomes) and cardiology trainees. A collaborative approach is key to accumulating information, minimising the risk of transmission and ensuring patient safety during the rapidly evolving COVID-19 pandemic.

Take Home Messages

COVID-19 has led to a major re-structuring of cardiac services within the UK (i.e. postponement of non-urgent elective procedures and rationalisation of acute services).
The major British cardiac societies have provided guidance which has helped inform a timely update of local hospital protocols and pathways.
Health care workers are advised to wear appropriate personal protective equipment to minimise the risk of viral transmission, with particular care during aerosol generating procedures. For Cardiology these are defined as “any procedure requiring or likely to require resuscitation for cardiac arrest involving cardiopulmonary resuscitation ± intubation and to transoesophageal echocardiography.”
Clinicians should be aware that changes to cardiology services due to COVID-19 may have adverse consequences for patients (e.g. delayed diagnosis and treatment resulting in worse outcomes) and cardiology trainees.
A collaborative approach is key to accumulating information, minimising the risk of transmission and ensuring patient safety during the rapidly evolving COVID-19 pandemic.

Introduction

On the 12^th March 2020, the World Health Organization (WHO) declared the novel Coronavirus disease 2019 (COVID-19) outbreak a global pandemic.¹ The virus, known as severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), which genetic sequencing has revealed is likely to originate from bats, has changed the world in a dramatic fashion. The National Health Service (NHS) is no exception. Indeed, in many hospitals across the UK the division according to specialty is no longer present; rather hospitals are simply divided into COVID and non-COVID areas. Many hospitals have surrendered their coronary care and day-case units to facilitate expansion of intensive care resources; and non-acute doctors have joined colleagues from general medicine, emergency departments or intensive care to serve in the frontline battle against COVID-19.

In response to the COVID-19 pandemic Public Health England recommend that hospitals postpone non-urgent elective work and rationalise acute services.²The present editorial provides an update on the impact of COVID-19 on cardiac procedures within the UK, and recommendations from the various British Cardiac Societies.

Protection against COVID-19 in the cardiac catheter laboratory

SARS-CoV-2 shares 75-80% of its viral genome with severe acute respiratory syndrome (SARS-1) and middle eastern respiratory syndrome (MERS),³ which infect intrapulmonary epithelial cells more than cells of the upper airways.⁴ SARS-CoV-2 enters cells via the human angiotensin-converting enzyme 2 cellular receptor,⁵ however appears to be more virulent due to an enhanced ability to mutate.³ The basic reproduction number (R0) of SARS-CoV-2 is 2.28, significantly higher than SARS-1 and MERS (1.88 and 0.47, respectively).6 Transmission of SARS-1 and MERS occurs primarily from patients with recognised illness by means of large droplets and contact and less so by aerosols and fomites.^7-9 The transmission of SARS-Cov-2 is assumed to be similar however there have been reports of transmission from asymptomatic carriers to cohabiting family members causing severe COVID-19 pneumonia, described as the “asymptomatic carrier” phenomenon.^10-¹² Concerns surrounding the spread of COVID-19 via healthcare workers has major implications for cardiac procedures.

Aerosol generating procedures can produce droplets <5 microns in size which, if inhaled can cause infection. Pathogens within air droplets can remain in the air and travel distance whilst still being infectious. It is critical that health care professionals working in the cardiac catheter laboratory know what type of personal protective equipment they should be using depending on the COVID-19 status of the patient and type of procedure (See Table 1 and Figure 1). Guidance is available from the British Cardiovascular Society (BCS) /British Cardiovascular Intervention Society (BCIS) / British Heart Rhythm Society (BHRS),¹³as well as Public Health England¹⁴and WHO.¹⁵

Table 1. Aerosol Generating Procedures requiring type 2 PPE
	World Health Organization¹⁵	BCS/BCIS/BHRS¹³
Definition	A medical procedure that results in the production of airborne particles (aerosols) which may be pathogenic.	Any procedure requiring or likely to require resuscitation for cardiac arrest involving CPR ± intubation and to transoesophageal echocardiography
Examples	Cardiopulmonary resuscitation Non-invasive ventilation (i.e. BiPAP, CPAP) Intubation/extubation Bronchoscopy Induction of sputum Airway suction Chest physiotherapy	Angiography/PCI post cardiac arrest Primary PCI Complex PCI VT ablation Cardiogenic shock Transoesphageal echocardiography
Guidance for health care workers undertaking aerosol generating procedures^13-15	limit procedures to those that are essential; carry out procedures in well-ventilated, negative pressure, single rooms with the doors shut; only healthcare workers needed to undertake the procedure should be present; healthcare workers should ensure they wear adequate PPE
BCS British Cardiovascular Society, BCIS British Cardiovascular Intervention Society, BHRS British Heart Rhythm Society, BiPAP bi-level positive airway pressure, CPAP continuous positive airway pressure, PCI percutaneous coronary intervention, PPE personal protective equipment, VT ventricular tachycardia, WHO World Health Organization.

Figure 1. Appropriate PPE in the cardiac catheter laboratory according to BCS/BCIS/BHRS¹³

	Type 1	Type 2
Components	Apron, gloves, surgical face mask, eye protection (if closer than 2m to patient)	Sterile fluid resistant gown, gloves, FFP respirator face mask, eye/face shield
Procedure type	Other procedures	Aerosol generating procedures
Examples	PCI for stable ACS (e.g. NSTEMI), routine permanent pacemaker implantation, transthoracic echocardiography.	Primary PCI, intubated patient, high risk of cardiac arrest^a, VT ablation, transoesophageal echocardiography.
^a High risk defined as resuscitated cardiac arrest, haemodynamically unstable, admitted via emergency department resuscitation area. Acute coronary syndrome, BCS British Cardiovascular Society, BCIS British Cardiovascular Interventional Society, BHRS British Heart Rhythm Society, DC direct current, NSTEMI non ST-elevation myocardial infarction, PCI percutaneous coronary intervention, PPE personal protective equipment.

Management of coronary artery disease

NHS England and NHS Improvement, with endorsement from the BCS ad BCIS have recommended to restructure cardiology services during the COVID-19 pandemic.¹⁵

For STEMI:

postpone all non-urgent elective procedures;
primary PCI should remain first line treatment for STEMI presenting within 12 hours of pain onset;
out of hospital arrests should only be transferred to a primary PCI centre if there is clear ST elevation and no other significant co-morbidities;
PCI centres that do not normally offer primary PCI for STEMI patients may undertake primary PCI during normal working hours;
in patients with COVID-19 and STEMI primary PCI remains first line but thrombolysis can be considered on a case-by-case basis where significant ambulance delays are anticipated;
patients can be managed in level 1 beds (i.e. cardiology ward, non-coronary care setting);
inpatient echocardiography and cardiac rehabilitation assessment is not necessary for stable patients.

In ACS (not STEMI):

acute coronary syndrome patients should be assessed on a case by case basis;
the usual NSTEMI pathways including PCI should continue;
optimal medical treatment without angiography for lower-risk NSTEMI patients and angiography in higher risk NSTEMI;
three vessel disease should be treated with PCI;
transcutaneous aortic valve implantation is preferred for treatment of severe aortic stenosis in acute situations.

To incorporate these recommendations PCI centres may need to modify existing primary PCI pathways for the following reasons: to incorporate assessment of COVID status early in the pathway; catheter laboratory utility may fall in order to reduce foot fall; fewer staff due to redeployment, sickness or social isolation policies; and overstretched ambulance transport services. An example of a primary PCI pathway from a tertiary centre is shown in Figure 2.

Figure 2. Example of a modified UK tertiary centre STEMI pathway

_{The STEMI pathway from the Morriston Cardiac Centre (Morriston Hospital, Swansea) was adapted in response to the COVID-19 pandemic. This centre has 3 catheter laboratories but only 2 are in operation since the pandemic. There is a separate “clean lab” for non-COVID patients and a separate “dirty lab” for suspected and confirmed COVID-19 cases. Each lab is deep cleaned after every procedure.}

_{CHDU cardiac high dependency unit, conserv Tx conservative treatment, DGH district general hospital, PPCI primary percutaneous coronary intervention, STEMI ST-segment elevation myocardial infarction, WAST Welsh Ambulance Service Trust.}

Cardiac rhythm management

Complex devices and electrophysiology considerations during the COVID-19 outbreak can be extrapolated from adaptations used for catheter laboratory procedures and PPE for high risk areas.¹¹ In addition NHS England¹⁵ recommend:

urgent bradycardia pacing and ablation of malignant arrhythmias should continue (i.e. high grade atrioventricular block, secondary prevention defibrillators, ventricular tachycardia ablation, generator replacements in pacing dependent patients, pre-excited atrial fibrillation);
device/lead extraction should continue for infection (i.e. bacteraemia, endocarditis, pocket infection)
decisions surrounding implantation of primary prevention defibrillators, or cardiac resynchronisation therapy for heart failure treatment is left to clinician judgement depending on the situation (see Table 2);
use of remote monitoring of devices where possible.

The American College of Cardiology along with the Heart Rhythm Society COVID-19 Task Force and the American Heart Association's Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology have also released new guidance for cardiac electrophysiology during COVID-19¹⁷which mirrors our guidance here in the UK.¹⁶

Table 2. Electrophysiology and devices procedures categorised by urgency¹⁶
Urgent procedures	Semi-urgent	Non urgent (Elective)
Catheter ablation VT ablation for medically refractory VT storm Atrial fibrillation, atrial flutter, or AV nodal ablation if hemodynamically significant, severely symptomatic, drug and/or cardioversion refractory Heart failure secondary to tachycardia WPW syndrome or pre-excited AF with syncope or cardiac arrest	Catheter ablation VT ablation for medically refractory recurrent ventricular arrhythmias SVT – medically refractory resulting in multiple ED visits	Catheter ablation PVC ablation in stable patient VT ablation for stable patient AF/AFL ablation in stable patient EP testing to evaluate stable tachyarrhythmias or bradycardia
Cardiac devices Lead revision for malfunction in a PPM dependent patient or ICD patient receiving inappropriate therapy Generator change in PPM dependent patient PPM or ICD with minimal battery remaining (e.g. EOL) Secondary prevention ICD/CRT-D PPM for symptomatic CHB, Mobitz II AVB, high grade AVB, severely symptomatic SND with long pauses Lead/device extraction for infection, including bacteraemia, endocarditis, or pocket infection	Cardiac devices Generator replacement for ERI battery replacement Primary prevention ICD in patient at high risk of life-threating ventricular arrhythmia	Cardiac devices Primary prevention ICD (case by case basis) CRT in stable patients CIED upgrade PPM for SND, Mobitz I AVB, stable non-high degree AVB, or tachy-brady syndrome in mildly symptomatic patient PPM or ICD generator replacements with >6 weeks of battery remaining Extraction of non-infected leads/device unless device function is dependent on lead extraction and re-implantation
Other Cardioversion for highly symptomatic atrial arrhythmias or uncontrollable RVR TOE for urgent cardioversion		Other Cardioversion of stable arrhythmias with well tolerated symptoms LAA closure in patients who can be on oral anticoagulation TEE for routine assessment of valves or LAA closure devices and cardioversion that can be done after appropriate period of anticoagulation Implantable loop recorder placement Tilt-table testing
AF atrial fibrillation, AFL atrial flutter, AV atrioventricular, AVB atrioventricular block, CHB complete heart block, CIED cardiac implantable electronic device, CRT cardiac resynchronisation therapy, ED emergency department, EOL end of life, EP electrophysiology, ERI elective replacement indicator, ICD implantable cardioverter defibrillator, ICU intensive care unit, LAA left atrial appendage, LBBB left bundle branch block, PPE personal protection equipment, PPM permanent pacemaker, PUI patient under investigation for COVID-19, SND sinus node dysfunction, SVT supraventricular tachycardia, TEE transesophageal echocardiography, VT ventricular tachycardia, WPW Wolff-Parkinson-White.

Table 2. Electrophysiology and devices procedures categorised by urgency¹⁶

Urgent procedures

Semi-urgent

Non urgent (Elective)

Catheter ablation

VT ablation for medically refractory VT storm
Atrial fibrillation, atrial flutter, or AV nodal ablation if hemodynamically significant, severely symptomatic, drug and/or cardioversion refractory
Heart failure secondary to tachycardia
WPW syndrome or pre-excited AF with syncope or cardiac arrest

Catheter ablation

VT ablation for medically refractory recurrent ventricular arrhythmias
SVT – medically refractory resulting in multiple ED visits

Catheter ablation

PVC ablation in stable patient
VT ablation for stable patient
AF/AFL ablation in stable patient
EP testing to evaluate stable tachyarrhythmias or bradycardia

Cardiac devices

Lead revision for malfunction in a PPM dependent patient or ICD patient receiving inappropriate therapy
Generator change in PPM dependent patient
PPM or ICD with minimal battery remaining (e.g. EOL)
Secondary prevention ICD/CRT-D
PPM for symptomatic CHB, Mobitz II AVB, high grade AVB, severely symptomatic SND with long pauses
Lead/device extraction for infection, including bacteraemia, endocarditis, or pocket infection

Cardiac devices

Generator replacement for ERI battery replacement
Primary prevention ICD in patient at high risk of life-threating ventricular arrhythmia

Cardiac devices

Primary prevention ICD (case by case basis)
CRT in stable patients
CIED upgrade
PPM for SND, Mobitz I AVB, stable non-high degree AVB, or tachy-brady syndrome in mildly symptomatic patient
PPM or ICD generator replacements with >6 weeks of battery remaining
Extraction of non-infected leads/device unless device function is dependent on lead extraction and re-implantation

Other

Cardioversion for highly symptomatic atrial arrhythmias or uncontrollable RVR
TOE for urgent cardioversion

Other

Cardioversion of stable arrhythmias with well tolerated symptoms
LAA closure in patients who can be on oral anticoagulation
TEE for routine assessment of valves or LAA closure devices and cardioversion that can be done after appropriate period of anticoagulation
Implantable loop recorder placement
Tilt-table testing

AF atrial fibrillation, AFL atrial flutter, AV atrioventricular, AVB atrioventricular block, CHB complete heart block, CIED cardiac implantable electronic device, CRT cardiac resynchronisation therapy, ED emergency department, EOL end of life, EP electrophysiology, ERI elective replacement indicator, ICD implantable cardioverter defibrillator, ICU intensive care unit, LAA left atrial appendage, LBBB left bundle branch block, PPE personal protection equipment, PPM permanent pacemaker, PUI patient under investigation for COVID-19, SND sinus node dysfunction, SVT supraventricular tachycardia, TEE transesophageal echocardiography, VT ventricular tachycardia, WPW Wolff-Parkinson-White.

Imaging

Echocardiography

The British Society of Echocardiography have published guidelines on transthoracic echocardiography (TTE) and TOE in the COVID-19 era.²⁶ The society reiterates concerns from its members with regards to aerosol spread given the very close face-to-face contact required during both TOE and TTE. It is recommended that TTE requests should now be triaged to perform only those that alter immediate medical management and can be level 1 scans (see BCS Editorial COVID-19: a practical guide to cardiac assessment and treatment).¹⁸ For patients with higher risk for COVID-19 a portable bedside echocardiogram is preferred. Access to elective echocardiography will be triaged on a case-by-case basis and performed in patients deemed at high risk (e.g. markedly elevated brain natriuretic peptide).

Cross sectional imaging

The European Association of Cardiovascular Imaging have produced guidelines regarding cardiac imaging during the COVID-19 pandemic.¹⁹ The key points from the guidelines are:

elective, non-urgent investigations can be postponed;
greater care is required to rationalise investigations in patients with suspected or confirmed COVID-19 infection;
measures are advised to reduce risk of transmission including portable echocardiography, limited the duration of the study (focused) and appropriate PPE should be used;
the potential role of cardiac computed tomography (CT) in the diagnosis of acute coronary syndrome in COVID-19 patients (i.e. raised troponin and suspected ACS), and can be performed at the same time as thoracic CT;
cardiac magnetic resonance imaging can be used in the acute setting to identify cardiac pathology in COVID-19 patients (e.g. myocarditis, Takotsubo cardiomyopathy).

Availability of cardiac CT, CMR and nuclear imaging will depend on local services. In some centres CMR has been adopted as first line for functional assessment of ischaemic heart disease as the scanning protocols pose a lower risk for transmission of COVID-19 compared to stress echocardiography.

Future implications

The COVID-19 pandemic has dramatically changed cardiology practice within the UK which has immediate and future implications. Since the COVID-19 pandemic, there has been an acute decline in cardiac hospitalisations such as MI and stroke across the UK,²⁰ likely as a result of patient fear of acquiring COVID-19 infection in hospital settings. Concerns have been raised as to whether these patients may be presently suffering in silence and are at risk of severe complications later during the pandemic. Public health initiatives are under way to try and encourage the general public to recognise serious cardiac symptoms and seek medical attention when needed.

There has been a restructuring of outpatient services with implementation of virtual clinics (e.g. telephone, video-conferencing), and remote monitoring instead of face-to-face visits where possible. These positive steps are encouraging however there is concern that cancellation of outpatient elective procedures may have serious consequences. Such patients may be at increased risk of: sudden cardiac death (e.g. primary prevention defibrillators); hospitalisation due to cardiac events (see Box 1); poorer outcomes due to postponement of intervention (e.g. aortic stenosis, atrial fibrillation ablation); receiving treatments associated with inferior outcomes (e.g. PCI in multivessel disease rather than coronary artery bypass surgery).

Box 1. Case – what are the consequences of postponing non-urgent PCI?

Case

An 80 year-old patient underwent elective PCI of left anterior descending artery for treatment of stable angina. Elective staged PCI of a severe proximal RCA lesion was scheduled but postponed due to the COVID-19 pandemic and subsequent NHS England recommendations. The patient presented 2 months following elective PCI with an inferior STEMI due to a thrombotic occlusion of the proximal RCA. Primary PCI was performed: a stent was placed within the RCA and the patient was discharged without complication.

Discussion

PCI in the setting of stable angina has not been shown to reduce risk of future myocardial infarction when compared to medical therapy however in this case the patient had a high-risk unstable lesion as evidenced by the inferior STEMI presentation. A sub-group of high risk patients are more likely to suffer from postponing non-urgent PCI and identifying such patients will be challenging.

Coronary angiogram showing severe proximal RCA lesion (A) and acute thrombotic occlusion (B).

NHS National Health Service, PCI percutaneous intervention, RCA right coronary artery, STEMI ST elevation myocardial infarction.

Finally, postponement of elective cardiology procedures has major implications for cardiology training within the UK. A recent BCS survey of primary PCI centres demonstrated that the number of cardiac catheter laboratories has approximately halved since the COVID-19 pandemic (unpublished data). Clinical research (excluding COVID-19) has largely stopped and many out of programme trainees undertaking research have returned to their original training centres. Cardiology trainees are likely to require extension of their training period to acquire competencies which may delay progression.

Conclusions

The COVID-19 pandemic has had an unprecedented impact on cardiac procedures worldwide and in the UK. The situation is rapidly evolving and the guidance is being updated continuously. It is likely that, as the number of COVID-19 positive cases increase, all patients presenting to hospital regardless of the symptom will be treated as potentially COVID-19 positive and the distinction between “low” and “high” risk of COVID-19 may cease to exist. It is also likely that we will become increasingly concerned with the non-presenters given the dramatic decrease in the incidence of acute conditions including myocardial infarctions and strokes that hospitals across the world have seen. A dynamic approach and information sharing between hospital trusts within the NHS and worldwide is going to be key in creating protocols and pathways that are constantly adapting to the COVID-19 pandemic.

References

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COVID-19: Impact on cardiology procedural services

Introduction

Protection against COVID-19 in the cardiac catheter laboratory

Management of coronary artery disease

Cardiac rhythm management

Imaging

Future implications

Conclusions

References

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