TAVR During the COVID-19 Pandemic

We appreciate the guidance provided in the American College of Cardiology/Society for Cardiovascular Angiography and Interventions consensus statement for structural heart disease intervention during the coronavirus disease 2019 pandemic (1). Although symptoms currently guide clinical practice guideline recommendations for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis, physiological variables may affect perceived acuity and time course for treatment. The Christ Hospital consensus clinical practice guidelines for performing TAVR during the moratorium on “elective” procedures include severe aortic stenosis and any of the following: 1) New York Heart Association functional class III or IV symptoms; 2) syncope; 3) mean gradient ≥50 mm Hg; 4) peak velocity ≥5 cm/s; and 5) objective evidence of a decline in left ventricular ejection fraction.

However, apparent lack of consensus in professional society recommendations may prompt practice modification. After adopting a “minimalist” approach to TAVR 6 years ago, we maintained anesthesiologist presence during TAVR for the occasional conscious sedation (monitored anesthesia care [MAC]) procedure requiring “conversion” to laryngeal mask airway or, rarely, general anesthesia (GA). Of note, the American Society of Anesthesiologists coronavirus disease 2019 frequently asked questions document (coronavirus resources for anesthesiologists) suggests replacing MAC for all TAVR patients (because of time delays in severe acute respiratory syndrome coronavirus-2 testing) with planned, controlled endotracheal anesthetics (2). This document asks, “What should we do about ‘MAC’ cases, with an open airway?” and answers, “If dispersion of potentially contaminated exhaled gases from an open airway (e.g. ‘MAC’) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered. The safety of you and your colleagues is paramount.” In this context, our anesthesiologists recommended conversion from MAC to GA for all TAVR patients. Like many programs, our move away from GA was accompanied by reductions in the incidence of hemodynamic instability, oropharyngeal and laryngeal trauma, post-procedural delirium, and urinary catheter–related events (trauma, infections). Following MAC, patient recovery was more rapid, intensive care unit admissions were reduced, and hospital discharge took place earlier. Faced with the prospect of GA for all TAVR procedures, conversion to nurse anesthesia was made rapidly, with one heart team physician assigned to monitoring sedation and hemodynamic status.

Last, patient perception may affect our ability to provide care. Despite acuity profiling and prioritization, patients may cancel scheduled TAVR procedures. Over the past 3 weeks, of 20 patients profiled as nonelective on the basis of clinical practice guidelines by a multidisciplinary committee, 6 canceled procedures largely because of fears of contracting coronavirus disease 2019 and family abandonment due to restrictive hospital visitation policies. One patient died suddenly after canceling. Furthermore, deferral for “low acuity” severe aortic stenosis is not benign. Deferred patients are called weekly by the TAVR coordinator. Despite this, 1 patient had sudden death 2 weeks after deferral. Counseling patients as to the consequences of treatment delay, the potential for clinical decompensation, and emergency hospital presentation are essential. Assurance that every effort to safely expedite their procedures and hospital stays may be helpful.