A BIBA MedTech Insights survey indicates that 50% of centres performing structural heart procedures believe that they will need to increase the number of operating days per week to manage the elective cases that have been put on hold because of COVID-19. However, 22% believe that no extra measures will be required and the backlog will be cleared in time.
The global outbreak of COVID-19, and its impact on resources, prompted many centres to postpone, or at least reduce, the elective procedures that they were performing. However, there are concerns that delayed procedures will lead to poorer prognosis in the long term for patients whose conditions may worsen because of lack of intervention. Additionally, postponement may cause a large backlog that will need to be addressed once elective procedures start to be reintroduced.
To better understand the impact of COVID-19 on elective procedures, BIBA MedTech Insights polled centres across the USA and Europe, asking interventional cardiologists and cardiac surgeons about the structural heart procedures that they were currently performing. Out of 220 centres, 49% said that they were only performing procedures for the most critical patients and 26% said that they were not performing any procedures at all. However, these figures did change depending on the procedure. For example, they were, respectively, 58% and 19% for transcatheter valve procedures (including transcatheter aortic valve implantation) vs. 25% and 53% for left atrial appendage occlusion. The figures also changed depending on whether the respondents were based in Europe or the USA, with a greater proportion of European respondents not performing any procedures than those in the USA (34% vs. 6%).
Given that some areas have now passed the peak of the pandemic, centres in these areas are looking to do elective procedures again. Therefore, the survey asked respondents what measures they felt would be required to clear the backlog of elective procedures. It found that 50% believed there would be a need to increase the number of operating days per week and 34% thought increasing the number of operating hours per day would be necessary. However, 22% felt there was no need for extra measures and the backlog would “clear in time”. See Figure 1.
Factors to consider when restarting procedures
In light of centres looking at the possibility of performing elective procedures again, David A Wood (Centre for Cardiovascular Innovation, St Paul’s and Vancouver General Hospital, Vancouver, Canada) and colleagues have published a joint guidance document in the Journal of the American College of Cardiology about the safe reintroduction of cardiovascular services during the pandemic. The document, which represents the views of several North American societies including the American College of Cardiology (ACC) and the Canadian Association of Interventional Cardiology (CAIC), outlined three areas that must be considered when reintroducing services, including: ethical considerations, such as maximising benefits by prioritising procedures that will ensure the most lives or life years are saved over those that benefit fewer people to a lesser degree; collaboration between regional public health officials, health authorities and cardiovascular care providers to manage the dynamic balance between provision of essential cardiovascular care and responding to future fluctuations in COVID-19 infections and hospital admissions; and the protection of patients and healthcare workers through regions having the necessary critical care capacity, personal protective equipment (PPE), and trained staff available, and a transparent plan for testing and re-testing potential patients and health care workers for COVID-19.
Athena Poppas, ACC president and one of the authors on the document, comments: “Unprecedented times call for unprecedented collaboration, and a collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease. It is essential that we work together to ensure cardiovascular disease patients are safely cared for during this pandemic and that we do not allow for a new crisis of undiagnosed, untreated or worsening cardiovascular disease to occur in the aftermath of this pandemic.”
The Society of Thoracic Surgeons (STS) have also reviewed the steps that need to be taken to reintroduce elective procedures. It hosted a webinar, moderated by STS president Joseph Dearani (Department of Cardiovascular Surgery, Mayo Clinic, Rochester, USA), on “reactivating cardiothoracic surgery programmes”. Its global panel included speakers from Europe, South Korea, and USA.
According to Domenico Pagano (Department of Cardiothoracic Surgery, University Hospital Birmingham, Birmingham, UK), the secretary general of the European Association for Cardio-Thoracic Surgery (EACTS), restarting cardiothoracic surgery depended on a number of things—such as the impact of COVID in the local region and the available resources. He added: “The less the COVID has had an impact on your area, the more you can open up for elective procedures.” In terms of which patients to bring in for a procedure, Pagano said it was “inevitable” that some patients would be disadvantaged during the pandemic because they would not receive any treatment or would receive the “second-best” treatment. “In my mind, decisions about which patients to treat is should not be made by any individual physician on their own. The role of the heart team is more important than ever,” he explained.
Another issue was testing patients for COVID-19 prior to them coming in for a procedure, with several panellists saying that all patients were tested. Tomislav Mihaljevic (Cleveland Clinic, Cleveland, USA) said that his centre had two testing pathways, with rapid testing for those with acute conditions and a longer test time for those who were non-acute. “The longer turnaround time [for non-acute patients] is to test 48 hours in advance so that we know the result of the test by the time that they reach the hospital,” he explained. Enrico Ruffini (Department of Thoracic Surgery, University of Torino, Torino, Italy) commented that, of non-acute patients, his hospital triaged patients by phone. He stated: “In case of any possible symptom, of course, we postpone the surgery for two weeks and then we test every patient on admission.”
However, while surgeons may be looking at restarting elective procedures, Valerie Rusch (Memorial Sloan Kettering Cancer Center, New York, USA) cautioned against assuming the COVID-19 pandemic was over. She said: “This infection is not about to disappear any time soon, so it is important to maintain capacity within our operating rooms to operate on COVID patients. We have developed an entirely separate pathway for how these patients enter the institution, go through their procedure, and recover from anaesthesia and get discharged home. That is a very important consideration in high incidence areas.”