Modeling the impact of delaying transcatheter aortic valve replacement for the treatment of aortic stenosis in the era of COVID-19

Abstract

Objective The aim of this study was to model the short term and 2-year overall survival for intermediate- and low-risk patients with severe symptomatic AS undergoing timely or delayed transcatheter aortic valve replacement during the 2019 novel coronavirus pandemic. Methods We developed a decision analysis model to evaluate two treatment strategies for both low-risk and intermediate-risk patients with aortic stenosis during the 2019 novel coronavirus pandemic. Results Prompt transcatheter aortic valve replacement resulted in improved 2-year overall survival when compared to delayed intervention for intermediate-risk patients (0.81 versus 0.67) and low-risk patients (0.95 vs 0.85), due to the risk of death or the need for urgent/emergent transcatheter aortic valve replacement in the waiting period. However, if the probability of acquiring the 2019 novel coronavirus is greater than 55% (intermediate risk patients) or 47% (low risk patients), delayed transcatheter aortic valve replacement is favorable to prompt intervention (0.66 vs 0.67, intermediate risk; 0.84 vs 0.85, low risk). Conclusions and Relevance Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe aortic stenosis results in improved 2-year survival when local healthcare system resources are not significantly constrained by the 2019 novel coronavirus.

Impact of COVID-19 on Management Strategies for Coronary and Structural Heart Disease Interventions

“…Patients awaiting structural heart disease (SHD) interventions constitute a particularly challenging group, as many have conditions that might be life threatening if the intervention is inappropriately delayed [ 25 •, 26 – 29 ]. Studies have shown a decline in surgical and transcatheter aortic valve procedures during the pandemic with potential increase in mortality [ 24 , 25 •, 26 – 29 ] (Fig. 1 ).…”

“…The investigators found that prompt TAVR resulted in improved 2-year overall survival compared with delayed intervention for intermediate- and low-risk patients; as delayed treatment was associated with death and need for urgent/emergent TAVR during the waiting period. In contrast, when the probability of acquiring COVID-19 was significant (> 55% for intermediate-risk patients or 47% for low-risk patients), delayed TAVR was favored over prompt intervention [ 29 ].…”

“…In the surgical field, hospitals around the country restricted the performance of elective surgery, including surgical aortic valve replacement (SAVR), to preserve ventilators, operating rooms, and ICU beds [ 27 , 29 , 30 ]. In this regard, TAVR, especially minimalist TAVR, has evolved as an appropriate alternative with less impact on hospital (and particularly critical care) capacity than SAVR in the current time where resource utilization is of paramount importance [ 29 , 30 ].…”

“…In the surgical field, hospitals around the country restricted the performance of elective surgery, including surgical aortic valve replacement (SAVR), to preserve ventilators, operating rooms, and ICU beds [ 27 , 29 , 30 ]. In this regard, TAVR, especially minimalist TAVR, has evolved as an appropriate alternative with less impact on hospital (and particularly critical care) capacity than SAVR in the current time where resource utilization is of paramount importance [ 29 , 30 ]. Some experts suggested alterations to the current evaluation of SAVR/TAVR practice during the COVID-19 crisis: with careful case selection, reviewing TAVR waiting list and triaging for high-risk patients (Table 2 ), reviewing SAVR waiting list and converting intermediate-risk patients to TAVR if appropriate, converting low-risk patients to TAVR with Heart Team consensus, avoiding TAVR work-up with TEE, use of coronary computed tomography instead of invasive coronary angiography in certain patients and efforts to make all tests in a single attendance for patients.…”

“…For ongoing trials, follow-up has been hampered during the COVID-19 crisis. To limit unnecessary physical contact and to reduce exposure, visits to medical centers have been canceled or postponed, and remote follow-up via phone or virtual visits have been implemented [ 2 , 3 , 29 ]. As such, some trial protocols have been modified to prioritize data.…”