Transcatheter Aortic Valve Implantation During COVID-19 Pandemic: The Device Also Matters

To the editor:

During Coronavirus Disease 2019 (COVID-19) pandemic, health systems were overwhelmed worldwide. Because of that, and also to reduce the risk of virus contamination, most elective invasive procedures were cancelled or postponed [1,2].

However, some patients pending on structural heart percutaneous interventions are also at high risk of cardiac events and even death if the procedure is postponed indefinitely, and may need to be treated even during pandemic. That is the case of trans-catheter aortic valve implantation (TAVI) [3], that is frequently indicated in patients with limited life expectancy if left untreated. Because of that, some recommendations about TAVI procedure during pandemic have been published [[4], [5], [6], [7]], including those recently published by Khan and co-workers [8]. These documents have included recommendations related with patient selection, health care workers protection and also technical and procedural instructions in order to reduce hospital stay (i.e. minimalistic approach). However, no guidance has been proposed in relation with preferences related with the type of device to implant, and this is of importance because of the growing number of different devices available in the market [9].

Trans-catheter aortic valves differ in many aspects, but during COVID-19 pandemic the risk of severe conduction abnormalities and vascular complications highlight because both lead to subsequent procedures (permanent pacemaker implantation and percutaneous or surgical vascular repair) that not only may increase the risk of virus contamination but also prolong hospital stay. In a recent study, both complications are among the most important factors leading to a prolonged hospital stay after TAVI [10]. Additionally, vascular and bleeding complications may explain ≈20% of deaths during hospitalization [11]. The Association of Interventional Cardiology from the Spanish Society of Cardiology (ACI-SEC) has included in their recommendations the importance of selecting a device with low rate of pacemaker implantation and low sheath, avoiding those needing >14 French sheaths [12]. The risk of severe conduction abnormalities is lower with the Acurate Neo (Boston Scientific) and balloon-expandable valves, in comparison with Corevalve (Medtronic Inc.), Portico (Abbott vascular) and Lotus (Boston Scientific) devices [13,14]. The risk of vascular complications is higher with larger sheaths. Although the rate of general complications is lower when operators use the device are more familiar with, device selection during COVID-19 pandemic should strongly consider these aspects.