Facilitating transcatheter aortic valve implantation in the era of COVID-19: Recommendations for programmes

Abstract

The COVID-19 pandemic continues to significantly impact the treatment of people living with aortic stenosis, and access to transcatheter aortic valve implantation. Transcatheter aortic valve implantation (TAVI) programmes require unique coordinated processes that are currently experiencing multiple disruptions and are guided by rapidly evolving protocols. We present a series of recommendations for TAVI programmes to adapt to the new demands, based on recent evidence and the international expertise of nurse leaders and collaborators in this field. Although recommended in most guidelines, the uptake of the role of the TAVI programme nurse is uneven across international regions. COVID-19 is further highlighting why a nurse-led central point of coordination and communication is a vital asset for patients and programmes. We propose an alternative streamlined evaluation pathway to minimize patients’ pre-procedure exposure to the hospital environment while ensuring appropriate treatment decision and shared decision-making. The competing demands created by COVID-19 require vigilant wait list management, with risk stratification, telephone surveillance and optimized triage and prioritization. A minimalist approach with close scrutiny of all parts of the procedure has become an imperative to avoid any complications and ensure patients’ accelerated recovery. Lastly, we outline a nurse-led protocol of rapid mobilization and reconditioning as an effective strategy to facilitate safe next-day discharge home. As the pandemic abates, TAVI programmes must facilitate access to care without compromising patient safety, enable hospitals to manage the competing demands created by COVID-19 and establish new processes to support patients living with valvular heart disease.

Indirect Impact of the COVID-19 Pandemic on Activity and Outcomes of Transcatheter and Surgical Treatment of Severe Aortic Stenosis in England

“…Our estimates surrounding the difference in the number of AVR procedures per month in 2020 compared with historic trends mean that there will likely be significant increased demand for TAVR and SAVR. This will lead to an inevitable increase in waiting times [32], and associated adverse impacts on outcomes [33]. Recommendations for how to manage this challenge are emerging [32,34].…”

“…This will lead to an inevitable increase in waiting times [32], and associated adverse impacts on outcomes [33]. Recommendations for how to manage this challenge are emerging [32,34]. Since the NACSA and UK TAVR registry datasets only contain data on those who undergo TAVR/SAVR, it was not possible for us to forecast future demand for AVR (since we do not have information on patients who are candidates for AVR, but who have not currently undergone the procedure).…”

Indirect Impact of the COVID-19 Pandemic on Activity and Outcomes of Transcatheter and Surgical Treatment of Aortic Stenosis in England

“…Namely, the results suggest that there will likely be significant increased future demand for TAVR and SAVR. This will lead to an inevitable increase in waiting times 34 and associated adverse impacts on outcomes. 35 Recommendations for how to manage this challenge are emerging.…”

“… 35 Recommendations for how to manage this challenge are emerging. 34 , 36 It was not possible for us to forecast future demand for AVR since we do not have information on patients who are candidates for AVR but who have not currently undergone the procedure. However, based on the available data, we estimated that, cumulatively, between March and November 2020, there were 4989 (95% CI, 4020–5959) cases of severe aortic stenosis who have not received treatment in England.…”

EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus From the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists With Endorsement From the Chinese Society of Cardiothoracic and Vascular Anesthesiology

“… If a non-intubated procedure is considered, we recommend that the patient wear a surgical mask to avoid environmental contamination and reduce the risk of contagion for health care providers who should wear full PPE. A local protocol including early mobilization, accelerated reconditioning, and early discharge planning should be developed ( 39 ). …”