key: cord-294242-amj0ohw3 authors: Li, Jia; Mazzone, Patrizio; Leung, Lisa; Lin, Weiqian; D'Angelo, Giuseppe; Ma, Jun; Li, Jin; Akhtar, Zaki; Li, Yuechun; Della Bella, Paolo E; Lin, Jiafeng; Gallagher, Mark M title: Electrophysiology in the time of coronavirus: coping with the great wave. date: 2020-03-30 journal: nan DOI: 10.1101/2020.03.30.20044776 sha: doc_id: 294242 cord_uid: amj0ohw3 Aims: To chart the effect of the COVID-19 pandemic on the activity of interventional electrophysiology services in affected regions. Methods: We reviewed the electrophysiology laboratory records in 3 affected cities: Wenzhou in China, Milan in Italy and London, United Kingdom. We interviewed electrophysiologists in each centre to gather information on the impact of the pandemic on working patterns and on the health of staff members. Results: There was a striking decline in interventional electrophysiology activity in each of the centres. The decline occurred within a week of the recognition of widespread community transmission of the virus in each region and shows a striking correlation with the national figures for new diagnoses of COVID-19 in each case. During the period of restriction, work-flow dropped to <5% of normal, consisting of emergency cases only. In 2 of 3 centres, electrophysiologists were redeployed to perform emergency work outside electrophysiology. Among the centres studied, only Wenzhou has seen a recovery from the restrictions in activity. Following an intense nationwide program of public health interventions, local transmission of COVID-19 ceased to be detectable after February 18th allowing the electrophysiology service to resume with a strict testing regime for all patients. Conclusion: Interventional electrophysiology is vulnerable to closure in times of great social difficulty including the COVID-19 pandemic. Intense public health intervention can permit suppression of local disease transmission allowing resumption of some normal activity. Informed consent was obtained from all participants/interviewees who took part in this study. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2020. . https://doi.org/10.1101/2020.03.30.20044776 doi: medRxiv preprint The COVID-19 pandemic has caused suffering and death across the world since late 2019. 1, 2 Physicians and journalists encountering the arrival of the epidemic in an area typically describe a wave, a tide or a tsunami of disease. It has had a widely publicised impact on the economy of afflicted areas. Medical services have suffered massive disruption. Even services far removed from respiratory medicine and critical care have suffered because of the diversion of resources needed to support the victims of the epidemic and through the illness of staff. As a resource-intensive speciality that deals predominantly with non-emergency cases, interventional electrophysiology is particularly vulnerable to disruption. While the pandemic disrupts the delivery of routine electrophysiology services, COVID-19 is associated with cardiac complications which could bring an additional burden of acute problems to electrophysiology. [3] [4] [5] The relative importance of the reduction in elective cases and any increase in emergency work is undefined. Wenzhou, Milan and London are each cities with a metropolitan area population of more than 4 million people; each has each been struck by the pandemic. During the initial months of 2020, Wenzhou experienced the greatest concentration of COVID-19 cases of any Chinese city outside the Hubei province. 6 Following an intense program of public health interventions 7 , new cases declined and have now vanished. As of March 27 th 2020, Wenzhou has had no new case of COVID-19 for the last 38 consecutive days. With this, many sectors have begun to return toward normality with stringent precautions. Milan was close to the centre of the Italian outbreak of COVA-19 and had to suspend all activity the first week in March. 8 London, like the rest of the United Kingdom has seen an abrupt rise in the disease incidence only since the second week of March 2020. 9 The disruption for cardiac electrophysiology labs has begun. We reviewed the catheter lab records of electrophysiology laboratories in a centre that experienced a high burden of COVID-19 early and near the origin of the pandemic and one in which the onset was delayed. The impact on workflow resulting from the redirection of staff and resources was correlated with the case-load of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2020. . https://doi.org/10.1101/2020.03.30.20044776 doi: medRxiv preprint COVID-19. We charted the burden of emergency procedures performed to look for evidence of any augmentation of these arising from COVID-19, and we interviewed the front-line cardiologists for information about arrhythmic complications encountered in the COVID-19 population. We looked for instances of COVID-19 infection acquired in hospital by electrophysiology patients and staff. We documented the protocols used to permit the resumption of activity after the first wave of the epidemic and examined the success of anti-infective precautions. The first diagnosis of COVID-19 in Wenzhou Medical University was in mid-January In each of the centres, routine activity of the EP lab was suspended within a week of the first locally diagnosed COVID-19 case in the hospital (table 1). The primary reason for the prompt suspension in each case was the concern that continuing to admit patients for elective procedures would expose patients to the risk of infection from undiagnosed COVID-19 patients already in the hospital. We encountered no instance of an arrhythmia occurring as a definable consequence of COVID-19 that required ablation as an emergency procedure. A small number of patients required emergency ablation during the period of restricted activity (table 2, figure 2), but this represented less than 5% of the normal workload of the centres. The distribution of cases was similar to that encountered in normal times with supraventricular tachycardia, ventricular tachycardia and atrial fibrillation all represented. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. One patient in London acquired COVID-19, apparently in hospital after her ablation. She died of pneumonia associated with the condition at 18 days after the ablation. Two electrophysiologists in London including a co-author of this paper acquired it and recovered without complication. Three nurses in a cardiology ward in Milan were infected, but none of the electrophysiologists. In Wenzhou, no staff member was infected. Of the centres involved, only Wenzhou has been able to resume routine activity. This At this visit, a nasal swab was analysed by PCR for evidence of the virus. 2) Patients with a satisfactory screening visit were admitted on the morning of the scheduled procedure and underwent a second nasal swab. If the PCR was negative for the virus, the procedure went ahead as planned. In all centres, outpatient activity was moved to a telephone-based or internet-based format in all possible cases from the time that widespread local transmission of the virus was recognised. Only those who were clinically urgent and were unable to to use a telephone or required an instrumental test were allowed to keep their physical All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Patients who had access to mobile-phone associated ECG recording were encouraged to use these and transmit recordings in preparation for telephone consultations. As part of social distancing, all EP educational meetings were suspended in all centres, and all major international meetings have been cancelled. Electronic learning has been put into practice across several medical disciplines and improving web-based educational tools. Major medical examinations such as the Membership exam (MRCP) and university entrance exams have been delayed indefinitely. The EP team in Wenzhou and that in London defaulted to emergency mode at the arrival of the first COVID cases. With elective work being cancelled, the electrophysiologists concentrated on urgent inpatient intervention including pacemaker implantation to minimist the time that any patient had to spend in hospital. The centres differed in their policies on redistributing staff to other duties. We have no gift to set a statesman right" William Yates 10 The electrophysiologist, like the poet is a luxury that society may dispense with when times are exceptionally difficult. Our work reduces or resolves troublesome symptoms; in narrow subgroups of the population that we serve, we may increase life expectancy, albeit marginally. In achieving this we expend resources that may be better used elsewhere in difficult times and we bring patients into a healthcare All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The results presented show that in representative centres from several of the worst- Severe acute respiratory syndrome coronarvirus-2 (SARS-CoV-2), the agent responsible for COVID-19 has an affinity for angiotensin converting enzyme 2 (ACE2) receptors. 11 This is central to the pathophysiology of the condition, leading to pneumonia and in critical stages, associated fulminant acute respiratory distress syndrome (ARDS) and multi-organ failure. 12 The primary affected organ is the lung but cardiovascular injury is also common. There is enhanced expression of ACE-2 in those with cardiovascular conditions, possibly accounting for the apparent greater severity of COVID-19 related illness in these patients. In one study, a majority (58%) of those with severe infection had a background of hypetension, and non-specifically 44% had a history of 'arrhythmia'. 13 Binding of the virus to ACE2 receptors in the lung and the heart initiates the acute inflammatory response. Pneumonia results, but also evidence of myocarditis; those with a rise in high-sensitivity Troponin I are more likely to require admission to intensive care. 14 There is a strong association between a history of hypertension and mortality from COVID-19. Systolic blood pressure was significantly higher in those with COVID-19 treated in intensive care units compared to those not requiring this level of care (144 versus 122, P<0.001). 14 This may relate to up-regulation of ACE2 receptors in those receiving ACE inhibiting drugs. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 13 It is not clear whether the apparent high mortality in patients with ischaemic heart disease represents an effect on ACE2 receptor expression, a vulnerability to ischaemic complications of the systemic illness or a bias against such patients when ventilatiors must be rationed. The pathophysiology of COVID-19 and its routes of systemic transmission remain incompletely understood. Observations had been noted of its neuroinvasive potential via peripheral neuronal trans-synaptic route and viral preponderance in organs with low expression of ACE2. 15 Brugada syndrome is a concern as the prolonged febrile illness characteristic of COVID-19 has the propensity to trigger arrhythmias. No such case has been reported, but like patients with heart failure and ischaemic heart disease, those with Brugada syndrome should take particular care to isolate themselves from likely sources of infection. No specific pharmacological therapy exists, but drugs being trialled in treating aspects of COVID-19 include anti-retrovirals and hydrochloroquine. These drugs may cause cardiotoxicitiy and prolong corrected QT intervals. No instance of a lifethreatening arrhythmia from this source has been reported. The risk of COVID-19 transmission to healthcare workers is high, with over 8% reported in Italy. 16 Ophthalmologists have been disproportionately affected, probably because of the close contact with the patients in whom conjunctivitis has been a presenting symptom. 17 Intensivists are at risk due to their inevitable extensive contact with severely affected patients and due to aerosol generation during intubation. Cardiology, including ablation and trans-esophageal echo also involves aerosol generating procedures (AGP) and close proximity to the patient. Under normal circumstances, a patient entering the cardiac catheter lab will encounter approximately 10 healthcare professionals before moving to a ward for recovery. The combination of numerous close contacts and fomites creates a risk of transmission. It makes sense to defer procedures whenever possible. Emergency All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2020. Many patients scheduled for EP procedures fall into categories at high risk of death if exposed to COVID-19. In the London cohort, the average age is 65, and >60% are male. 18 Co-existing diabetes, hypertension or heart failure are common. All of these, particularly hypertension are strong risk factors for COVID-19 related mortality. It was therefore obligatory to halt the performance of routine ablation procedures until the risk recedes. Not all EP patients can wait on indefinitely. Guidelines published by NHS England, 19 include narrow criteria for ablation in this crisis, recommending that it is limited to cases of rapidly conducted pre-excited atrial fibrillation, heart failure secondary to tachycardia, and ventricular tachycardia that is controllable with medication. All of the ablations conducted in all 3 centres during the period of restricted activity met these criteria ( figure 2, table 2) . Strict guidelines were put in place in each centre to minimise the risk to patients and staff in cases where ablation had to be performed. Local protocols mirored published All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 20 Strict isolation measures were applied before and after any procedure. During the procedure, staff wore PPE. The reduction in electrophysiology caseload related to the pandemic will effect the EP industry. Companies which supply equipment have shut offices and distribution networks. Loss of revenue will last for many months. Companies may prosper and may help the fight against the pandemic by switching production to items of relevance to that fight: Ventilators and associated equipment, viral test kits and thermometers. In China, the official recognition of the seriousness of the outbreak and the take-over by central government of direct responsibility for its handling coincided with the introduction of an integrated set of measures. 7 Best publicised was the lock-down of society and industry to achieve extreme social distancing. The less-publicised adjunct to the lock-down was the introduction of a system for screening all persons with fever or with a history of contact with known cases, so that they could be isolated in designated facilities. The use of electronic technology and surveillance served as an adjunct to these measures. has not yet been developed. The experience from Wenzhou shows that with energetic public health intervention, the epidemic may be suppressed, and normal life may resume with precautions. In the longer term, a vaccine may permit us to dispense with these precautions. The less stringent interventions chosen by the UK and other North European countries All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2020. . https://doi.org/10.1101/2020.03.30.20044776 doi: medRxiv preprint risk allowing a lingering epidemic that drags on for so long that by the time a vaccine comes, production and supply chains will have fallen into habitual disuse and operators will have lost familiarity with their craft. Many patients will also have died by then. In the Spring of 2020, as in the Summer of 1914, it feels as though "the lamps are going out all over Europe", but there is reason for hope. Vigorous public health measures have suppressed the epidemic in parts of Asia, permitting a resumption of some normal routine activity with stringent precautions. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronarvirus disease-2019 (COVID-19): The epidemic and the challenges A novel coronavirus outbreak of global health concern Sars-cOv-2: a potential novel etiology of fulminant myocarditis Coronarvirus Fulminant Myocarditis Saved With Glucocorticoid and Human Immunoglobulin All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted doi: medRxiv preprint 6. Clinical findings in a group of patients infected with the 2019 novel coronarvirus (SARS-CoV-2) outside of Wuhan, China: a retrospective case series China's local governments are combating COVID-19 with unprecedented responses-from a Wenzhou governance perspective COVID-19 pandemic: perspectives on an unfolding crisis World Health Organisation (WHO) coronarvirus disease In: Edith Wharton, The Book of the Homeless Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus orgins and receptor binding Epidemiological and clinical characteristics of 99 cases of 2019 novel coronarvirus pneumonia in Wuhan, China: a descriptive study COVID-19 and the cardiovascular system Clinical features of patients infected with 2019 novel coronavirus in Wuhan The neuroinvasive potential of SARS-CoV2 may play a role in respiratory failure of COVID-19 patients Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted Graefe's Archive for Clinical and Experimental Ophthalmology Improving Esophageal Protection during AF ablation: the IMPACT study NHS England Publication; 001559 version 1. Clinical guide for the management of cardiology patients during the coronavirus pandemic. 2020; 1-5. specialty-guide-cardiolgy-coronavirus-v1-20-march Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC's Interventional Council and SCAI Viscount Grey of Fallodon: Twenty-Five Years 1892-1916 All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. In each of the electrophysiology labs, routine activity was cancelled as soon as the country detected significant numbers of COVID-19 cases. During the period of suspension of routine activity, very few emergency procedures were performed. Of the 3 centres, only Wenzhou had been able to resume normal activity. All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The pie-charts indicate the mean number of each category of each procedure carried out per week in 2020 in each centre in the period before COVID-19 arrived, in the period of restricted activity and in the case of Wenzhou after the resumption of normal activity. The workload during the period of crisis represents the mean number of cases per week per centre across all 3 centres, and represents a fall of more than 95% compared to pre-crisis activity without a clear-cut alteration in the breakdown of procedure types. None declared. All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.