- In the COVID-19 era, the frequency and setting of assessing patients with severe aortic stenosis (AS) should be stratified on the basis of symptom severity, as well as the risk of mortality from delays in care and susceptibility to COVID-19 infection
- For aortic valve replacement (AVR), the choice between surgical AVR (SAVR) and transcatheter AVR (TAVR) should still be made by a heart team
- SAVR is still preferred for younger, low-risk patients, especially those in whom mechanical AVR is being considered, those with unfavorable anatomy for TAVR and those with additional indications for cardiac surgery
- Particularly during the COVID-era, since TAVR usually requires a shorter hospital length of stay and less resource utilization compared to SAVR, it should be preferred for patients who would receive a bioprosthetic valve or elderly patients
- After SAVR, accelerate extubation and transfer out of the ICU; after TAVR, target hospital discharge within 24 hours; for both procedures, focus on accelerated physical therapy, occupational therapy and speech-language therapy
Managing patients with severe aortic stenosis (AS) has been especially challenging during the COVID-19 pandemic. During surges, elective procedures have to be postponed to mitigate infection, but these patients are at increased risk of mortality from delays in care. They are also at higher than average risk of developing COVID-19 because they are typically older and have cardiometabolic comorbidities.
In JACC: Cardiovascular Interventions, Varsha K. Tanguturi, MD, cardiologist, Sammy Elmariah, MD, MPH, director of Interventional Cardiology Research in the Corrigan Minehan Heart Center at Massachusetts General Hospital, and colleagues recently recommended best practices for managing patients with severe AS under the resource constraints imposed by COVID-19.
Outpatient Surveillance and Risk Stratification
Normally, any form of symptomatic severe AS is considered urgent, but in the COVID-19 era, patients should be surveilled on the basis of symptom severity:
- Asymptomatic—Monitor every six months by virtual visit; perform transthoracic echocardiography (TTE) for new-onset symptoms or other changes in clinical status
- Mild, stable symptoms—Assess virtually every 1–3 months; defer examination/referral for consideration of aortic valve replacement (AVR) until the pandemic abates
- Moderate, stable symptoms—Monitor virtually every 1–2 weeks or treat urgently on the basis of resource availability
- Severe or unstable symptoms (New York Heart Association functional class III or IV congestive heart failure symptoms, progressive weight gain, rapidly decreasing exertional capacity or symptoms with minimal exertion, progressive or severe angina, syncope, new-onset pre-syncope)—In-person assessment and repeat TTE may be required to assess for new left ventricular dysfunction; urgent AVR, if indicated, is prudent despite COVID-19–related risks
Involving family members in virtual visits can facilitate surveillance and improve clinicians' decision-making. The article provides guidance for choosing between inpatient and virtual assessment of the need for AVR and how to conduct virtual assessments.
Surgical vs. Transcatheter AVR
The choice between surgical AVR (SAVR) and transcatheter AVR (TAVR) should still be made by a heart team; the Society for Thoracic Surgeons (STS) Resource Utilization Tool may be useful. The article gives guidance about how to tailor subsequent testing and imaging accordingly to limit exposure to the novel coronavirus.
SAVR is still preferred for younger, low-risk patients, especially those in whom mechanical AVR is being considered, those with unfavorable anatomy for TAVR and those with additional indications for cardiac surgery.
TAVR should be favored for elderly patients and those being considered for bioprosthetic valves because it usually requires a shorter hospital stay and eliminates the need for operating room resources.
When possible, TAVR should be performed under monitored anesthesia care and TTE guidance to avoid aerosol generation.
The authors recommend:
- Accelerating extubation and transfer out of the ICU after SAVR
- Targeting hospital discharge within 24 hours after TAVR
- For both SAVR and TAVR, focusing on accelerated physical therapy, occupational therapy and speech-language therapy to support rapid mobilization and diet advancement
- For patients with conduction disturbances that don't require permanent pacemaker implantation, mobilizing cardiac telemetry monitors should be preferred to prolonged hospitalization
- Per STS guidelines, defer 30-day follow-up echocardiographic assessment after TAVR in the absence of clinical concerns
Patients with COVID-19
Management and evaluation of severe AS should be deferred in patients with active COVID-19 in the absence of the need for emergent AVR.
If COVID-19 is severe and cardiac decompensation is hindering clinical recovery, balloon aortic valvuloplasty or emergent TAVR can be considered. SAVR should be undertaken only in extreme cases, given the inflammatory response and pulmonary dysfunction commonly seen after cardiopulmonary bypass.
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