key: cord-0887544-gn9atlp3
authors: Pothineni, Naga Venkata K.; Santangeli, Pasquale
title: Electrophysiology and Interventional Cardiology Procedure Volumes During the COVID-19 Pandemic
date: 2021-10-30
journal: Card Electrophysiol Clin
DOI: 10.1016/j.ccep.2021.10.011
sha: be9991cbfdcd9552bd46e4d9d2e632d3ae84cf19
doc_id: 887544
cord_uid: gn9atlp3

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has imposed an unprecedented health care crisis across the globe. Health care efforts across the world have been diverted to tackling the pandemic since early 2020. Hospitals and health care systems have undertaken major restructuring in an effort to deliver health care to an increasing number of patients affected by COVID-19. Although great focus has been placed on treating those individuals suffering from COVID-19, clinicians must simultaneously balance caring for patients who are not actively infected. In anticipation of an exponential increase in COVID-19 cases, health care systems developed strategies to channel available resources to meet the rapidly rising demands of COVID-19. This change was noticed significantly in the field of invasive cardiology as well. Many cardiac catheterization and electrophysiology (EP) laboratories canceled elective procedures to limit the burden on hospital resources and preserve personal protective equipment (PPE). Major societies published guidance statements delineating patient selection for procedures during the exponential phase of the pandemic growth. Patient care was triaged and those waiting for elective procedures were managed with expectant care or noninvasive approaches to preserve hospital resources and personnel. In the current article, we review the impact of the COVID-19 pandemic and its response to the volume of interventional cardiology (IC) and EP procedures across the world.

The coronavirus disease 2019 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has imposed an unprecedented healthcare crisis across the globe. Health care efforts across the world have bene diverted to tackling the pandemic since early 2020. Hospitals and health care systems have undertaken major restructuring in and effort to deliver health care to an increasing number of patients affected by . While great focus has been placed on treating those individuals suffering from COVID-19, clinicians must simultaneously balance caring for patients who are not actively infected. In anticipation of an exponential increase in COVID-19 cases, healthcare systems developed strategies to channel available resources to meet the rapidly rising demands of COVID-19. This change was noticed significantly in the field of invasive cardiology as well.

Many cardiac catheterization and electrophysiology (EP) laboratories canceled elective procedures to limit the burden on hospital resources and preserve personal protective equipment (PPE). Major societies published guidance statements delineating patient selection for procedures during the exponential phase of the pandemic growth. 1 Patient care was triaged and those waiting for elective procedures were managed with expectant care or noninvasive approaches to preserve hospital resources and personnel. In the current manuscript, we review the impact of the COVID-19 pandemic and its response on volume of interventional cardiology (IC) and EP procedures across the world.

Onset of the COVID -19 pandemic led to immediate cessation of multiple clinical services in the field of interventional cardiology for better resource allocation and avoidance of potential exposure, across various countries. The British Cardiovascular Interventional society J o u r n a l P r e -p r o o f conducted a retrospective study of all percutaneous coronary interventions (PCI) in the United Kingdom during the lockdown imposed by the pandemic, and compared them to PCI volumes in the pre pandemic period. 2 They showed that PCI volumes fell down by 49% with the greatest decrease in PCI for stable angina (66% reduction). PCI for ST elevation MI (STEMI) was also down by 33%. Interestingly, the decline in volume was higher in older patients and in minorities.

In another study from the United Kingdom, Mohamed et al evaluated trends in all inpatient cardiac procedures to understand national trends during the lockdown period. 3 Data on interventional cardiac catheterization, PCI), electrophysiological (CIED implantation, catheter ablation), structural (TAVR) and surgical (CABG, SAVR, MVR) procedures were collected and compared to trends in preceding years. Overall procedural volume fell down by approximately 89% in April and May 2020 during the lockdown, with cardiac catheterization and CIED implantation being the most affected. In addition, after adjusting for baseline comorbidities, patients undergoing PCI and CIED implantation in the lockdown period had higher odds of mortality. A 24% reduction (29% for NSTEMI and 18% for STEMI) in overall PCI volume for acute MI was also reported from a multicenter analysis from Ireland. 4 Despite prioritization of STEMI care when other interventional services were limited during the lockdown, a reduction was seen in STEMI activations and primary PCI procedures being performed, partly related to patient's reluctance to seek medical care during an ongoing pandemic. A single center cross sectional study from Germany reported a 50% reduction in admissions and primary PCI for acute MI during the early part of the pandemic compared to pre pandemic level. 5 More importantly, patients presenting with an acute MI during the pandemic had symptoms for a longer duration, presented with lower LV ejection fraction, had more immediate complications and 3 times higher mortality compared to the pre pandemic levels.

Similar results have been reported from other European countries such as Italy and Portugal. 6,7 A systematic review pooling data from 32 studies showed significantly prolonged door to balloon time and worse inpatient mortality for primary PCI for STEMI during the pandemic compared to pre pandemic times. 8 To better understand STEMI care during the pandemic, multi center registries were developed. The International Study on Acute Coronary Syndromes-ST Elevation Myocardial Infarction (ISACS-STEMI) registry included data from 6609 patients that underwent primary PCI at 77 hospitals in 18 European countries. 9 There was a significant reduction in volume of primary PCI in 2020 compared to 2019, along with significantly longer door to balloon times, and higher in-hospital mortality. The NACMI (North American COVID-19 and STEMI) prospective registry was developed to track STEMI management trends in COVID patients. 10 This prospective multicenter study showed that patients with COVID presenting with STEMI were less likely to receive primary PCI compared to controls and had higher rates of a composite of death, stroke, recurrent MI and need for repeat revascularization.

Data on change in transcatheter aortic valve implantation volumes during the pandemic has been limited compared to studies evaluating PCI. While experience from the UK showed no significant decline 3 , a survey from Asia showed a 25% reduction in case volume due to the pandemic. 11

Response to the pandemic has also led to a reduction in EP procedures performed. During period. 14 In this study, data from 9 hospitals spanning 2017-2020 in the Catalonia province were aggregated. Compared to the pre-COVID-19 period, an absolute decrease of 56.5% was observed (54.7% in PM and 63.7% in ICD) in CIED implantation rates. Interestingly, there was no statistically significant differences in type of PM or ICD implanted. An analysis of all cardiac procedures in the United Kingdom also revealed an 89% and 56% reduction in catheter ablation and CIED implantation procedures in April 2020 compared to similar time periods in preceding years. 3 Similar reduction in CIED volumes from Germany and Italy have been reported as well. 15, 16 J o u r n a l P r e -p r o o f

Following periods of lockdown in various geographic regions, resumption of elective procedures presented a challenge. While measures to screen for symptomatic individuals for COVID-19 were widely available, risk of asymptomatic carriers transmitting infection to healthcare workers and other patients remained. Several infection control precautions were undertaken at many centers to combat this risk. As more tests became available, universal testing of patients had led to safer resumption of elective services.

A prospective study of universal testing of all patients undergoing interventional and EP procedures has provided insight into a strategy of safe resumptions of elective procedures. 17 In this study conducted at the University of Pennsylvania, the following measures were instituteduniversal surgical masks and temperature screening for all employees and patients, automated telephone pre-procedure symptom screening for patients, strict restrictions on visitors for inpatients and outpatients, and universal pre-procedure PCR testing to detect SARS-CoV-2 virus in patients undergoing elective or urgent procedures. Additional precautions to prevent cross contamination were implemented at all feasible sites ( Table 1) . All in-patients undergoing cardiac catheterization or EP procedures underwent nasopharyngeal swabs for SARS-CoV-2 PCR testing performed at the hospital where the procedure was being performed. Outpatients were encouraged to undergo pre-procedural testing at a satellite clinic 24 hours prior to the scheduled procedure to off load burden at the main hospital. 

Not surprisingly, reduction in procedural volumes during the COVID-19 pandemic has impacted training of fellows enrolled in interventional and EP training programs. Singla et al conducted a survey of all EP fellows and program directors in the United States to assess impact of the pandemic on EP training and education. 18 Out of 99 fellows that responded, 98% reported a decrease in their procedural volume and 55% of fellows reported a period of furlough or quarantine during the acute surge of COVID. A similar survey of 14 interventional cardiology programs in New York city also reported significant reduction in catheterization procedures performed by fellows. 19 In this survey, more than two-thirds of interventional program directors opined that the pandemic has moderately to severely impacted fellowship training. 21% felt that fellows would graduate without performing 250 percutaneous coronary interventions (PCI), which is considered a minimum cut off for graduation. A third of fellows and program directors felt that fellowship training should be extended to those impacted by the pandemic. Shah et al. 

Development of a vaccine that is highly effective against moderate to severe COVID has been a remarkable achievement. Increased vaccine uptake has led to a major reduction in hospitalizations for COVID and enabled reopening to a state of near normalcy across the world.

However, waves and surges of COVID are expected to happen due to ongoing mutations in the virus and development of variants. 22 For instance, the current delta variant leading to surges in some parts of the United States has led to a rapid rise in hospitalizations again, overwhelming health care resources in some hospitals. 23 While healthcare systems are more equipped to handle surges compared to the onset of the pandemic, these surges can lead to cancellation of elective procedures again, impacting interventional and EP volumes as well. Lessons learnt from early 2020 can be used to better plan for effective and uninterrupted delivery of routine health care for chronic conditions, while handling the acute needs of an ongoing pandemic. There is no doubt that societal and governmental efforts to improve vaccine delivery and overall vaccination rates are pivotal to allow health care systems to effectively function. 

Guidance for Cardiac Electrophysiology During the COVID-19 Pandemic from the Heart Rhythm Society COVID-19 Task Force

Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology

Impact of the COVID-19 Pandemic on Percutaneous Coronary Intervention in England: Insights From the British Cardiovascular Intervention Society PCI Database Cohort

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality

Impact on percutaneous coronary intervention for acute coronary syndromes during the COVID-19 outbreak in a non-overwhelmed European healthcare system: COVID-19 ACS-PCI experience in Ireland

Increased mortality and worse cardiac outcome of acute myocardial infarction during the early COVID-19 pandemic. ESC Heart Fail

Impact of SARS-CoV-2 pandemic on ST-elevation myocardial infarction admissions and outcomes in a Portuguese primary percutaneous coronary intervention center: Preliminary Data

Impact of COVID-19 pandemic and infection on in hospital survival for patients presenting with acute coronary syndromes: A multicenter registry

The Global Impact of the COVID-19 Pandemic on STEMI care: A Systematic Review and Meta-Analysis

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry

Initial Findings From the North American

Transcatheter aortic valve implantation during the COVID-19 pandemic: Clinical expert opinion and consensus statement for Asia

Reduction in new cardiac electronic device implantations in Catalonia during COVID-19

on behalf of Helios hospitals Group. Emergency hospital admissions and interventional treatments for heart failure and cardiac arrhythmias in Germany during the Covid-19 outbreak: insights from the Germanwide Helios hospital network

Impact of the COVID-19 Pandemic on a Tertiary-Level Electrophysiology Laboratory in Italy

Patient and Staff Perceptions of Universal Severe Acute Respiratory Syndrome Coronavirus 2 Screening Prior to Cardiac Catheterization and Electrophysiology Laboratory Procedures

The Impact of the COVID-19 Pandemic on Cardiac Electrophysiology Training: A Survey Study

Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter

Impact of the COVID-19 pandemic on interventional cardiology training in the United States

How the COVID-19 Pandemic Has Affected Cardiology Fellow Training

Reduced sensitivity of SARS-CoV-2 variant Delta to antibody neutralization