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Challenges for electrophysiology during and after the Covid-19 pandemic

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Current situation in electrophysiology

During the COVID-19 pandemic, the daily routines in most hospitals changed dramatically. Every hand was needed to provide medical care for COVID-19 patients or to prepare for their arrival.

To protect patients and staff from COVID-19 exposure, it was necessary to postpone all non-urgent or non-emergent electrophysiological procedures,1 especially because arrhythmias are an additional health risk with COVID-19.

Meanwhile it is clear, that COVID-19 affects multiple organs including the heart. A report from Wuhan (China) showed that 16.7% of hospitalized and 44.4% of ICU patients with COVID-19 had arrhythmias1, which is an additional challenge for electrophysiologists. COVID-19 positive patients may require electrical cardioversions, CIED implants and endomyocardial biopsies.2

The joint COVID-19 guidelines of AHA, ACC and HRS can help to establish new workflows and to prioritise procedures. According to them, a case is considered urgent, when there is a life-threatening situation or the threat of permanent organ dysfunction.1

Examples for urgent procedures are ventricular tachycardia (VT) ablation in a hemodynamically compromised patients or other severe tachycardia not responding to antiarrhythmic drugs.1

New routines

New routines have been established to restart activities in the laboratories and ensure maximum safety at the same time.

If possible, testing for SARS-CoV-2 should be pursued before every treatment.1 Performing procedures on COVID-19 patients in the electrophysiology (EP) laboratory should be avoided. If necessary, a bedside procedure (e.g. temporary ventricular pacemaker) can be considered, to prevent transmission of the virus to the EP laboratory (as the virus was recently shown to stay viable for up to 72 hours on stainless steel surfaces3). If it is inevitable to perform a procedure on a COVID-19 positive patient, a specific room for infected patients should be used. A negative pressure procedure room is ideal for treating COVID-19 infected patients.

Personal protection equipment should consist of at least FFP2 masks.4

 

New workflows

The following practical advice has proven to be useful during the COVID-19 pandemic:

  • In COVID-19 positive cases, EP procedures should be scheduled at the end of the day to facilitate disinfection and cleaning.2
  • In order to free up needed ICU capacities, urgent procedures can be performed on extended weekday and weekend hours.3
  • Single operator cases should be pursued to preserve personal protective equipment (PPE) and prevent doctor to doctor transmission.1 As this is going to have a significant impact on the education and training of EP fellows, the HRS has published recommendations related to education and procedural participation during the pandemic.
  • As the care team is restricted to the procedure room until the procedure has finished, all supplies and equipment should be in the room at the start of the case. Device technicians and nurses should keep a distance of more than six feet from the patient.3
  • Procedure time should be minimized, if possible. This includes, for example, avoiding extensive VT induction and activation mapping to reduce risk.1
  • If a patient is at high risk for respiratory failure, endotracheal intubation should be performed in the patient's room to prevent aerosolization of viral particles.
  • Same day discharges after device implant should be considered to minimize the patient’s risk of nosocomial infection.1 Tele-health and remote checks should be used, whenever feasible.1 After device implantation, each patient can be discharged with remote monitoring device.3
  • During ablations or extractions, the use of intracardiac echocardiography instead of anaesthesia-operated transesophageal echocardiography can prevent aerosolization and unburden anaesthesiologists, who are needed at the ICU.3

A NEW DIMENSION IN EP

Innovative techniques can help to meet the different needs during the COVID-19 pandemic. As procedure time should be minimized, novel technologies can enable faster, easier and more precise EP procedures. The cooperation between BIOTRONIK and Acutus has facilitated the development of a suite of such technologies to map, visualize and ablate transient and variant rhythms.

Rapid and consistent mapping of arrhythmias in three minutes or less allows for an efficient map-ablate-remap strategy, thereby enabling hospitals to catch up with the backlog of procedures that had to be postponed during the start of the COVID-19 pandemic. In addition, reconstruction of CT-like heart anatomy by noncontact ultrasound-based 3D imaging from inside the heart can help to avoid aerosolization through transesophageal ultrasound during the COVID-19 pandemic.

 

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Sources

  1. Lakkireddy DR et al. 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, American Heart Association. Heart Rhythm 2020. Online ahead of print.
  2. Mazzone P et al. The COVID-19 challenge to cardiac electrophysiologists: optimizing resources at a referral center. J Interv Card Electrophysiol 2020: 1-7
  3. Rubin GA et al. Performance of electrophysiology procedures at an academic medical center amidst the 2020 coronavirus (COVID‐19) pandemic. J Cardiovasc Electrophysiol 2020: 31(6):1249-1254
  4. Robert Koch-Institut: Empfehlungen des RKI zu Hygienemaßnahmen im Rahmen der Behandlung und Pflege von Patienten mit einer Infektion durch SARS-CoV-2. www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Hygiene.html, Stand 5.6.2020
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