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Managing Aortic Stenosis in the Age of COVID-19

Managing Aortic Stenosis in the Age of COVID-19 Invited Commentary | Cardiology Preparing for the Second Wave Thoralf M. Sundt, MD To state the obvious, the world is in the grip of a pandemic with profound health implications beyond Related articles mortality associated with severe acute respiratory syndrome coronavirus 2 itself. Its impact on the Author affiliations and article information are delivery of health care that would otherwise be classified as routine is profound, if subtle. listed at the end of this article. Cardiovascular conditions requiring inpatient procedures, such as interventions to treat symptomatic aortic stenosis, are among those that are clearly lifesaving and among those contributing to a hidden mortality of coronavirus disease 2019 (COVID-19). Whether one chooses to interpret the current state of the pandemic as an ongoing first wave—perhaps with a nadir in some regions—or as the quiet before a second wave, there is a clear need for tools permitting precise triage of patients by the urgency with which procedures should be performed. The studies by Ryffel et al from Switzerland and Ro et al from New York aim to help clinicians in that regard. In the study by Ryffel and colleagues from Bern, Switzerland, criteria similar to those established by the American College of Cardiology and Society for Cardiovascular Angiography and Interventions consensus statement, namely expedited aortic valve replacement (AVR) for area of 0.6 cm or less or transvalvular mean gradient of 60 mm Hg of greater, recent cardiac decompensation symptoms with minimal exertion, were applied. Almost 20% of deferred patients reached the composite end point of all-cause mortality, stroke, and unplanned cardiac hospitalization with the presence of multivalve disease a risk factor. I cannot tell if the authors considered this to be evidence of success or failure, but perhaps apart from adding patients with combined valve disease to the expedited list, it looks to me like success. Most events were hospitalizations, and the only stroke was in a patient who underwent transcatheter AVR. There were no deaths, which highlights the difficulty of composite end points that include occurrences with such widely disparate implications as hospitalization and death. In the study from New York by Ro et al, where the COVID-19–associated crisis in terms of limited hospital resources was much more severe, essentially all patients were deferred pending accelerating symptoms of dyspnea, angina at rest, heart failure, or syncope. This is clearly an undesirable approach, as 10% of patients had cardiac events, including urgent transcatheter AVR in 6 patients and cardiac death in 2 patients. Lower ejection fraction, associated coronary artery disease, and more advanced heart failure (New York Heart Association class III and IV) were risk factors associated with poor outcomes, suggesting that transcatheter AVR not be deferred. 1,2 Taken together, these studies provide useful guidance. First, as we have known for many years, symptomatic aortic stenosis is a life-threatening condition, and its treatment cannot be considered elective in any way. Patients with the most echocardiographically severe stenosis, clinically advanced symptoms, or comorbid coronary artery disease or lung disease belong at the 1 2 head of the line. And although not addressed by the studies by Ryffel et al or Ro et al, it certainly makes sense that, all things being equal, from the patient’s standpoint transcatheter AVR is preferable to surgical AVR, given shorter hospitalization and consequent exposure of patients to COVID-19 in hospital and rehabilitation centers. This is true from the standpoint of the health care system as well, undoubtedly conserving intensive care unit and hospital beds relative to surgical AVR. Indeed, the same can be said of proceeding with appropriately expedited procedures even if a second wave of COVID-19 hits. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(9):e2020368. doi:10.1001/jamanetworkopen.2020.20368 (Reprinted) September 30, 2020 1/2 JAMA Network Open | Cardiology Managing Aortic Stenosis in the Age of COVID-19 ARTICLE INFORMATION Published: September 30, 2020. doi:10.1001/jamanetworkopen.2020.20368 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Sundt TM. JAMA Network Open. Corresponding Author: Thoralf M. Sundt, MD, Cox 652, Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (tsundt@mgh.harvard.edu). Author Affiliations: Division of Cardiac Surgery, Massachusetts General Hospital, Boston; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston; Department of Surgery, Harvard Medical School, Boston, Massachusetts. Conflict of Interest Disclosures: None reported. REFERENCES 1. Ryffel C, Lanz J, Corpataux N, et al. Mortality, stroke, and hospitalization associated with deferred vs expedited aortic valve replacement in patients referred for symptomatic severe aortic stenosis during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2020402. doi:10.1001/jamanetworkopen.2020.20402 2. Ro R, Khera S, Tang GHL, et al. Characteristics and outcomes of patients deferred for transcatheter aortic valve replacement because of COVID-19. JAMA Netw Open. 2020;3(9):2019081. doi:10.1001/jamanetworkopen. 2020.19801 3. Shah PB, Welt FGP, Mahmud E, et al; American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic: an ACC/SCAI position statement. JACC Cardiovasc Interv. 2020;13 (12):1484-1488. doi:10.1016/j.jcin.2020.04.001 JAMA Network Open. 2020;3(9):e2020368. doi:10.1001/jamanetworkopen.2020.20368 (Reprinted) September 30, 2020 2/2 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Managing Aortic Stenosis in the Age of COVID-19

JAMA Network Open , Volume 3 (9) – Sep 30, 2020

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American Medical Association
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Copyright 2020 Sundt TM. JAMA Network Open.
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2574-3805
DOI
10.1001/jamanetworkopen.2020.20368
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Abstract

Invited Commentary | Cardiology Preparing for the Second Wave Thoralf M. Sundt, MD To state the obvious, the world is in the grip of a pandemic with profound health implications beyond Related articles mortality associated with severe acute respiratory syndrome coronavirus 2 itself. Its impact on the Author affiliations and article information are delivery of health care that would otherwise be classified as routine is profound, if subtle. listed at the end of this article. Cardiovascular conditions requiring inpatient procedures, such as interventions to treat symptomatic aortic stenosis, are among those that are clearly lifesaving and among those contributing to a hidden mortality of coronavirus disease 2019 (COVID-19). Whether one chooses to interpret the current state of the pandemic as an ongoing first wave—perhaps with a nadir in some regions—or as the quiet before a second wave, there is a clear need for tools permitting precise triage of patients by the urgency with which procedures should be performed. The studies by Ryffel et al from Switzerland and Ro et al from New York aim to help clinicians in that regard. In the study by Ryffel and colleagues from Bern, Switzerland, criteria similar to those established by the American College of Cardiology and Society for Cardiovascular Angiography and Interventions consensus statement, namely expedited aortic valve replacement (AVR) for area of 0.6 cm or less or transvalvular mean gradient of 60 mm Hg of greater, recent cardiac decompensation symptoms with minimal exertion, were applied. Almost 20% of deferred patients reached the composite end point of all-cause mortality, stroke, and unplanned cardiac hospitalization with the presence of multivalve disease a risk factor. I cannot tell if the authors considered this to be evidence of success or failure, but perhaps apart from adding patients with combined valve disease to the expedited list, it looks to me like success. Most events were hospitalizations, and the only stroke was in a patient who underwent transcatheter AVR. There were no deaths, which highlights the difficulty of composite end points that include occurrences with such widely disparate implications as hospitalization and death. In the study from New York by Ro et al, where the COVID-19–associated crisis in terms of limited hospital resources was much more severe, essentially all patients were deferred pending accelerating symptoms of dyspnea, angina at rest, heart failure, or syncope. This is clearly an undesirable approach, as 10% of patients had cardiac events, including urgent transcatheter AVR in 6 patients and cardiac death in 2 patients. Lower ejection fraction, associated coronary artery disease, and more advanced heart failure (New York Heart Association class III and IV) were risk factors associated with poor outcomes, suggesting that transcatheter AVR not be deferred. 1,2 Taken together, these studies provide useful guidance. First, as we have known for many years, symptomatic aortic stenosis is a life-threatening condition, and its treatment cannot be considered elective in any way. Patients with the most echocardiographically severe stenosis, clinically advanced symptoms, or comorbid coronary artery disease or lung disease belong at the 1 2 head of the line. And although not addressed by the studies by Ryffel et al or Ro et al, it certainly makes sense that, all things being equal, from the patient’s standpoint transcatheter AVR is preferable to surgical AVR, given shorter hospitalization and consequent exposure of patients to COVID-19 in hospital and rehabilitation centers. This is true from the standpoint of the health care system as well, undoubtedly conserving intensive care unit and hospital beds relative to surgical AVR. Indeed, the same can be said of proceeding with appropriately expedited procedures even if a second wave of COVID-19 hits. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(9):e2020368. doi:10.1001/jamanetworkopen.2020.20368 (Reprinted) September 30, 2020 1/2 JAMA Network Open | Cardiology Managing Aortic Stenosis in the Age of COVID-19 ARTICLE INFORMATION Published: September 30, 2020. doi:10.1001/jamanetworkopen.2020.20368 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Sundt TM. JAMA Network Open. Corresponding Author: Thoralf M. Sundt, MD, Cox 652, Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (tsundt@mgh.harvard.edu). Author Affiliations: Division of Cardiac Surgery, Massachusetts General Hospital, Boston; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston; Department of Surgery, Harvard Medical School, Boston, Massachusetts. Conflict of Interest Disclosures: None reported. REFERENCES 1. Ryffel C, Lanz J, Corpataux N, et al. Mortality, stroke, and hospitalization associated with deferred vs expedited aortic valve replacement in patients referred for symptomatic severe aortic stenosis during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2020402. doi:10.1001/jamanetworkopen.2020.20402 2. Ro R, Khera S, Tang GHL, et al. Characteristics and outcomes of patients deferred for transcatheter aortic valve replacement because of COVID-19. JAMA Netw Open. 2020;3(9):2019081. doi:10.1001/jamanetworkopen. 2020.19801 3. Shah PB, Welt FGP, Mahmud E, et al; American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic: an ACC/SCAI position statement. JACC Cardiovasc Interv. 2020;13 (12):1484-1488. doi:10.1016/j.jcin.2020.04.001 JAMA Network Open. 2020;3(9):e2020368. doi:10.1001/jamanetworkopen.2020.20368 (Reprinted) September 30, 2020 2/2

Journal

JAMA Network OpenAmerican Medical Association

Published: Sep 30, 2020

References