key: cord-0892161-21c60vhp authors: Wang, Norman C.; Jain, Sandeep K.; Estes, N.A. Mark; Barrington, William W.; Bazaz, Raveen; Bhonsale, Aditya; Kancharla, Krishna; Shalaby, Alaa A.; Voigt, Andrew H.; Saba, Samir title: Priority plan for invasive cardiac electrophysiology procedures during the coronavirus disease 2019 (COVID‐19) pandemic date: 2020-04-23 journal: J Cardiovasc Electrophysiol DOI: 10.1111/jce.14478 sha: 901136116f2c4fbe1126a3b36c5b31fbf27675c3 doc_id: 892161 cord_uid: 21c60vhp nan urgent/nonelective, (b) semi-urgent, and (c) nonurgent/elective. The purpose of this manuscript is to provide a priority plan for invasive cardiac electrophysiology procedures during the COVID-19 pandemic that is consistent with, yet simplified in comparison to, prior recommendations. [6] [7] [8] [9] [10] 2 | SAFETY AND RESOURCE UTILIZATION The primary population-level intervention to combat COVID-19 is social distancing. Slowing dissemination of SARS-CoV-2 has been challenging as an estimated 80% of infected individuals are asymptomatic or mildly symptomatic yet may still shed the virus. 2 CoV-2 can survive on surfaces, particularly plastic and stainless steel, for up to 72 hours. 3 Lack of widespread availability of accurate testing has complicated numerical estimates of cases. Minimizing exposure time to high-risk environments is essential. Family members and healthcare workers in close contact with infected individuals are high-risk groups. 2 The 3 at-risk groups when considering invasive cardiac electrophysiology procedures are patients, the general population, and hospital personnel. For patients without COVID-19, the potential benefit of a procedure must be balanced with additional interactions with hospital personnel and time in the hospital. Older age and co-existing medical conditions are associated with increased mortality risk and should be taken into consideration. 2 Undiagnosed asymptomatic or minimally symptomatic hospital personnel with COVID-19 may still be working. While a goal of a procedure may be to shorten hospitalization time or to decrease the risk of rehospitalization, complications may markedly increase hospital stay and, consequently, infection risk. Acquisition of SARS-CoV-2 may also increase exposure to the general population after discharge. Personnel within the cardiac electrophysiology laboratory should consult with their in-hospital infection prevention and control section for institution-specific considerations. The minimum number of personnel should be involved with patients with known or suspected COVID-19, and trainee participation is discouraged. All workers should be trained and fitted for personal protective equipment (PPE). N95 masks or powered air-purifying respirators are recommended for COVID-19 cases. 9,10 PPE utilization must account for limited supplies that may be needed later for worst-case scenarios. Increasing availability of SARS-CoV-2 testing should allow more accurate stratification of PPE needs in the procedure planning phase. A major potential consequence of exposure to the cardiac electrophysiology team is that quarantine would make them temporarily unavailable. Hospitals in geographical regions with a high prevalence of COVID-19, or "hot zones," have reported shortages in PPE, intensive care unit beds, and mechanical ventilators. In these locations, the threshold to consider invasive cardiac electrophysiology procedures may increase even higher. Certain procedures may strain personnel and equipment from various sections. For example, catheter ablation for atrial fibrillation may involve anesthesia and cardiac imaging. Procedurally related adverse events that require intensive care unit monitoring and mechanical ventilation may jeopardize resources needed to treat patients with COVID-19, particularly if a local surge develops. As organizations have called for stoppage to elective procedures, 6-10 this may result in liability. The overarching principle is that all invasive cardiac electrophysiology procedures that can be reasonably postponed without compromising patient safety should be, until further guidance is available. It is unclear how long postponement of elective procedures will continue to be advised. Reasonable noninvasive options that allow for expedited discharge are preferred. Challenges for cardiac electrophysiology, like many medical and surgical specialties, are present when differentiating elective versus nonelective procedures. 10 However, guidelines and consensus statements have been issued by ACC, AHA, and HRS. These have standardized systems that categorize therapies by "Classification of Recommendation." 11 The following priority plan, presented in the Proactively documenting the rationale for nonelective procedures is worth considering. Procedures and scenarios in this category have class I or IIa recommendations with patients at high short-term risk for mortality or major morbidity. Examples include catheter ablation for medically refractory monomorphic ventricular tachycardia in nonischemic cardiomyopathy; catheter ablation for Wolff-Parkinson-White Syndrome associated with rapid atrial fibrillation and syncope; permanent pacemaker for symptomatic complete heart block; and lead extraction for an infected cardiovascular implantable electronic device in the setting of persistent bacteremia. A secondary prevention ICD has a class I recommendation and is preferred before discharge. However, a temporary wearable cardioverter-defibrillator may be a reasonable option to explore given unique circumstances that may arise from the COVID-19 pandemic. Catheter ablation for antiarrhythmic-refractory persistent rapid atrial fibrillation with heart failure and recent recurrent hospitalizations, particularly possible tachycardia-induced cardiomyopathy, is a situation that may be considered nonelective. Conversely, catheter ablation for amiodarone-refractory ischemic ventricular tachycardia with mild-to-moderate symptoms that terminated with antitachycardia pacing has a class I recommendation, 11 but may be elective. The potential benefits for procedures and scenarios in this category are long-term. Some may have medical options that are reasonable alternatives. The risk for short-term morbidity or mortality is low. Such situations include left atrial appendage occlusion (although recent stroke or major bleed may elevate the priority to equivocal); catheter ablation for symptomatic idiopathic premature ventricular complexes; catheter ablation for rate-controlled but symptomatic atrial fibrillation or flutter; most primary prevention ICDs; and permanent pacemaker for symptomatic chronotropic incompetence without syncope or near-syncope. The priority plan for invasive cardiac electrophysiology procedures presented here is a flexible yet organized method to facilitate triage during the COVID-19 pandemic. Procedure priority should be decided proactively and with social distancing in mind. Uncertainty or A novel coronavirus from patients with pneumonia in China Characteristics of and important lessons from coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 Clinical management and infection control of SARS: lessons learned First case of 2019 novel coronavirus in the United States COVID-19): interim guidance for healthcare facilities COVID-19: recommendations for management of elective surgical procedures CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response HRS COVID-19 task force message Guidance for cardiac electrophysiology during the coronavirus (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 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death Priority plan for invasive cardiac electrophysiology procedures during the coronavirus disease 2019 (COVID-19) pandemic