COVID-19 and the Cath Lab: What to Do?

Reprinted with permission from Cath Lab Digest.

In the coronavirus pandemic, EMS has been focusing on best practices for the treatment and transport of patients under investigation (PUI) who have signs and symptoms consistent with the virus. However, EMS providers are clearly continuing to treat patients with other emergencies, including cardiovascular emergencies such as acute coronary syndrome (ACS) and myocardial infarctions both with and without ST-elevation.

How will PUI needing cardiac catheterization affect operations? Here interventional cardiologist Morton J. Kern, MD, explores some of the questions facing cardiologists in the cath lab. Kern is chief of medicine for the Veterans Administration Long Beach Healthcare System and staff and professor of medicine in the Division of Cardiology at the University California, Irvine (UCI).

In terms of modifying current protocols, Kern recommends that “EMS providers who are treating patients with ACS and an NSTEMI should provide medical management without activating the cath lab.”

Below Kern explores other considerations.

Kern: One of my colleagues asked this critical question: “How are cath labs around the USA and the globe managing STEMI and other cardiac emergencies in patients with suspected COVID-19 that would normally have resulted in a trip to the cath lab? Are you adopting an approach similar to that employed in Sichuan, China,¹ where STEMI is largely relegated to lytic therapy? Is it business as usual with added preventive measures for healthcare providers, or something in between?”

There is no doubt we have moved into a new era of world health.² At this time the full effects of the COVID-19 pandemic have only begun to be felt (Figure 1). Universities, businesses, schools, and entertainment venues have all canceled, closed, or postponed large meetings and concentrations of participants. Hospital systems have already curtailed industry representative visits to cath labs, limiting them to those absolutely necessary for safe patient care. Quarantines, both enforced and voluntary, are a good first step and hopefully not too late to mitigate the illness (Figure 2).

What Should We Do to Protect Cath Lab Staff and Patients?

Many questions are still unanswered, but many have proposed some practical and hopefully effective approaches. Here Kern and Arnold Seto, MD, a cardiologist at UCI, offer some opinions.

Are we at the point of canceling elective cases?

Kern: Not yet.

Seto: Soon.

Are healthcare professionals (technologists/nurses) allowed to decline participation in cases with a known or suspected COVID-19 patient?

Kern: They can, just as they can decline any activity if they are concerned about their safety. 

Seto: Not in this time of crisis. Healthcare professionals have an obligation to patients when there are reasonably effective safeguards (gown, masks, shields). 

If taking on a COVID-19 patient leads to quarantine of all participating personnel for two weeks, what is the loss in capacity to other patients?

Kern: Huge. 

Seto: Huge. 

What precautions are needed to minimize exposure to staff and other patients?

Kern: Full personal protective equipment. 

Seto: Some discussions of negative-pressure rooms, airborne precautions vs. droplet and mask. Minimize staff in the room. Terminal clean and possibly longer 4–6-hour clean. 

Does it ever make sense to do a cath procedure on a COVID-19 patient, especially with a demand-related non-STEMI? 

Kern: Not immediately, unless they are unstable. 

Seto: No, see Zeng, et al.¹ 

Should we only do STEMIs, or none at all? 

Kern: Maybe we should think about thrombolytics. 

Seto: Strongly consider thrombolytics to avoid exposure to staff. 

Is a cath lab a critical operation of a hospital at this time, or should critical care RNs and physicians be diverted to ICU care? 

Kern: With elective volumes reduced sharing workloads makes sense, but we should not risk losing specially trained cath lab staff to the ICU. The cath lab may be required for pLVAD implantation. 

Seto: It depends on number of staff available, but reserve at least 1–2 24-hour teams to maintain care of cardiac emergencies. Given their unique skills, cath lab staff should preferably be diverted to non-COVID-19 patients only. 

What Did They Do in China?

Authors led by Jie Zeng, professor of chemistry at the University of Science and Technology of China, reported in a letter to Intensive Care Medicine how to balance acute myocardial infarction and COVID-19. They published the protocols from Sichuan Provincial People’s Hospital, a large medical center massively affected by the epidemic. I have paraphrased some of the most important points here:

For STEMI patients:

• Stable patients when the onset time is within 12 hours—Use thrombolytics.
• Stable patients when the onset time is more than 12 hours—Evaluate risk of PCI vs. infection. Obtain echocardiogram at 24–48 hours. Follow-up should be performed through an Internet outpatient clinic.
• Unstable patients with severe pneumonia—Admit to isolation ward.
• Unstable patients with mild to moderate pneumonia—Assess the onset time of STEMI and see above.

For non-STEMI, the door-to-balloon time is not critical in most patients. Therefore, first exclude the SARS-CoV-2 infection. Any confirmed case should be transferred to the isolation ward until patient recovery and then assessed for further invasive interventions as needed.

What Should We Do Now?

Certainly no one can speak for the whole country on cath lab protocols at this point, but here are comments from two interventional colleagues:

Prashant Kaul, Piedmont Heart Institute, Atlanta, Ga.—We are proposing a similar protocol based on the Sichuan experience both for high risk or confirmed COVID cases that present with STEMI. Similarly, patients who are confirmed positive (or at high risk) with some other “urgent” need to come to the cath lab (hemodynamically or electrically unstable, tamponade) will be evaluated on a case-by-case basis, with attempts made to avoid coming to the lab. If possible, we will consider bedside IABP [intra-aortic balloon pump] placement or bedside pericardiocentesis as appropriate. There are multiple implications to bringing a COVID-positive patient to the lab for the rest of the staff, lab flow (the room will be offline for several hours to clean), and in situations where the COVID-positive patient needs to be emergently intubated during the procedure.

Kirk Garrett, ChristianaCare, Wilmington, Del.—My take on this issue: Primary PCI is still preferred for those with presumed or confirmed diagnosis if you’re able to provide personal protective equipment to team members. Isolation and ’lysis may be an option for those with uncontrolled cough and confirmed infection or febrile respiratory illness, if not lytic contraindications. The lab will need a terminal clean after each confirmed/suspected case, but right now the prevalence of the disease is still low in our community. Of course that is subject to change.

References

1. Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital. Intensive Care Med, 2020 Mar 11 [epub ahead of print].

2. Huang CL, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020 Feb 15; 395(10,223): 497–506.

3. Pueyo T. Coronavirus: why you must act now. Politicians, community leaders and business leaders: what should you do and when? Medium, 2020 Mar 10; https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca.

Additional Resources

Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci USA, 2007 May 1; 104(18): 7,582–7.

Tabarrok A. What worked in 1918–1919? Marginal Revolution, 2020 Mar 7; https://marginalrevolution.com/marginalrevolution/2020/03/what-worked-in-1918-1919.html.

Morton J. Kern, MD, is a professor at the University of California, Irvine School of Medicine and chief of medicine for the VA Long Beach Healthcare System.