The Impact of COVID-19 Pandemic on the Hospital Management of TAVI Patients: TAVI Team Thoughts and Recommendation

2.1. Symptomatic Severe Aortic Stenosis

Immediate TAVI should be considered for patients with severe symptomatic AS associated with a reduction in EF thought to be secondary to AS, presence of class III-IV congestive heart failure (CHF), and syncope secondary to AS.

2.2. Asymptomatic Severe to Critical AS

For asymptomatic patients, we recommend to postpone the TAVI procedure for three months or until after hospital services resume elective procedures. Close outpatient monitoring, possibly via telehealth, should be continued for all patients with severe AS.

2.3. Virtual Clinic Follow up

TAVI centers should establish a system that provides weekly telephone follow-up for patients whose procedures have been delayed. It is expected that some of these patients will develop worsening of their symptoms and will require their cardiac intervention to be performed more urgently during the pandemic.

2.4. Virtual Heart Team Meetings

We recommend that the TAVI team convene virtually on at least a weekly basis to review the status of AS patients on the “waiting” list. Interventional cardiologist and cardiac surgeon should assume a leadership position and should be given the authority to arbitrate challenging cases. No triage system can accurately identify all patients who should safely be deferred; the triage system should be individualized to each medical center, patient population served, and the pandemic's local impact.

Our adjusted recommendation is in line with the document from the Canadian Association of Interventional Cardiology. The fundamental principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients/staff and maintaining the overall healthcare resources [10].

3.1. Cardiac Imaging Department Preparedness

The patients undergoing TAVI procedure will undergo a Computer Tomographic scan (CT) to prepare them for the TAVI procedure. Hence, the cardiac imaging developed a set of policies and procedures aimed at achieving sufficient capacity for continued operation during a health care emergency and optimize the care of patients with COVID-19 [11,12].

• 1)

  Implementation of standard policy and procedures for a patient with known or suspected COVID-19 exposure.

• 2)

  Imaging only for those patients where imaging will impact management.

• 3)

  The application of the standard protocols for decontamination after caring for COVID-19 patient.

• 4)

  Encourage improving the capability for remote imaging interpretation

3.2. Local Anesthesia with Conscious Sedation (LACS) Versus General Anesthesia and Intubation

The use of general anesthesia for the TAVI procedure ensures patient stability. However, a few studies have demonstrated the feasibility of TAVI with the patient under local anesthesia with conscious sedation [13]. This has the advantage of being less invasive, a shorter procedure time, a shorter intensive care unit stay, an earlier recovery, and a shorter hospital stay [14]. Local anesthesia with conscious sedation may be considered as the best anesthesia technique during this crisis provided that the patient is not in decompensated heart failure, can lie flat in the bed, and not morbidly obese. However, the anesthesia team should be prepared to use general anesthesia at any time during the procedure [15–17]. This approach is particularly crucial at this crisis, where the majority of TAVI patients will not utilize the intensive care unit for their recovery after the procedure, and this is important as critical care beds will be limited during the COVID-19 crisis in many countries. PCI should only be performed before TAVI when coronary artery disease is contributing to the patient's clinical presentation.

3.3. TAVI Team Personnel

The TAVI team consists of interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, and nurse specialists. The TAVI team carries the responsibility to conduct virtual TAVI clinics, to follow up the patients on the waiting list, and select those who need to be done during the crisis without any delay. Depending on the potential exposure of the HCWs to COVID-19 infection, both within the hospital and out of the workplace, team members may need to be quarantined or treated for illness. Hence, consideration of scheduling using designated separate teams should help address interruptions due to the temporary absence of team personnel.

3.4. Practical Recommendations for the Catheter Laboratory During the COVID-19 Pandemic

• 1)

  COVID-19 designated intervention catheter laboratories with negative room (air) pressure

• 2)

  Only essential staff or personnel should be allowed access into the catheter laboratory.

• 3)

  Clinical discussions between medical staff should be performed via phone, if possible.

• 4)

  Limit the amount of contact between groups of nursing/medical teams.

• 5)

  Limit waiting times for patients in the catheter laboratory corridor.

• 6)

  Accept patients only when ready in a catheter laboratory after the team has done with PPE.

• 7)

  Ensure there will be adequate personnel for the physical transfer of the patient onto the catheter lab bed (registrar/fellow, scrub nurse, and a minimum of 2 additional staff who are transferring patient).

• 8)

  The door between the control room and catheter lab should be “closed."

• 9)

  All non-essential pieces of equipment should be stored outside the procedure room, preferably in cabinets.