Cath Lab Digest talks with:
Michael C. Reed, MD, Director of Structural Heart Intervention, International Heart Institute, Providence St. Patrick’s Hospital, Missoula, Montana;
Brian K. Whisenant, MD, Director, Structural Heart Disease, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
Can you tell us about your TAVR program?
Michael Reed, MD: I am an interventional cardiologist in Missoula, Montana, as part of Providence St. Patrick’s Hospital. I work in a group called the International Heart Institute, which includes several cardiologists, cardiac surgeons, and advanced practice providers all working together to provide structural heart care for Montana. Providence St. Patrick’s Hospital is a community hospital and we mainly provide services for western Montana. There are three transcatheter aortic valve replacement (TAVR) programs in the state, with us being one. We started with our program a little over six years ago.
Brian Whisenant, MD: I am also an interventional cardiologist, in Salt Lake City, Utah, at Intermountain Medical Center. Our TAVR program started in 2009 in the PARTNER trial. We did about 330 TAVRs last year, and are now doing about 2 TAVRs a week in our current coronavirus situation.
Can you tell us more about how the pandemic affected your TAVR programs?
Michael Reed, MD: When we were at the height of our TAVR volume, we were implanting four or five valves a week. We did a little over 200 valves last year. Now that number, understandably, is significantly lower. We are implanting one or two valves a week, mostly based on precautions in our hospital. We have limited our procedural volume to urgent or emergent procedures, and also procedures (TAVR being one) where we think it isn’t safe to wait for two months. We are trying to be selective in the cases that we do without delaying patients in an unsafe manner, but certainly in this culture of uncertainty about whether to expect a surge of patients and limitations with hospital resources such as personal protective equipment (PPE), we are proceeding cautiously, seeking a balance between treating patients for their aortic stenosis and not overexposing our staff or our patients unnecessarily. It has been a challenge, but something that I know our team is up for.
Brian Whisenant, MD: In our program, we were consistently doing 25 to 30 valves a month. We had been slowly increasing over the past year, but in the past month, we have decreased to about two valves per week. Utah, like most states in the country, experienced a governor-mandated halting of all elective procedures. Even more importantly, we have not been seeing the same level of referrals that we were seeing before. As a result, the cases that we have been doing are primarily patients who were transferred from an outside facility or admitted through the emergency department with acute heart failure, which has given us about two cases per week. We have a backlog of patients who we call regularly and invite them to come in for TAVR if they feel that their symptoms are significant. Utah just lifted its ban on elective procedures. Our hospital has tiered levels of care. We were red, meaning no elective procedures, and now are orange, defined as no procedures that require overnight stay or intubation. However, the hospital has been receptive as we have discussed how aortic valve patients are not truly elective and that we need to provide symptomatic patients with necessary care.
How are you assessing aortic valve disease patients?
Michael Reed, MD: It is really a balance between what patients are comfortable with, what the referring doctors are comfortable with, and what we are physically capable of doing, either by state mandate or by local institution. On the flip side of that, however, are certain risk factors that we have identified, where patients will experience problems if their cases are delayed. Some of these risk factors are anatomic, some are echocardiographic, and some are clinical. With regard to echocardiographic or anatomic features, if patients have a severely reduced ejection fraction, critically narrow valve area, or a prosthetic valve that has failed, we are going to be more aggressive in treating these patients and feel less comfortable in delaying. From a clinical perspective, severe symptoms, ie, symptoms of heart failure or angina, certainly syncope, are patients where we are going to act more quickly. For people who don’t necessarily fall into those categories, we are calling them once a week to assess whether their symptoms have changed, and maintain a low threshold to bring them in. We are also in constant communication with our ICU staff and administrators to survey the current situation in regard to hospital capacity and PPE. We are working very closely together to try and identify the timing for everything. It’s a moving target.
Brian Whisenant, MD: We try to empower patients so that they know that they have a voice in all aspects of their care. Patients are scared of the hospital and are reluctant to come in. Our prevalence of COVID-19 in the hospital is quite low. We try to segregate patients so that cardiac patients are not in the same units with COVID patients. We tell patients that if they need something done, we are available and ready to take care of them. We involve them in the decision regarding if and when to proceed, and make sure they know how to contact us when they are concerned.
Have you discussed with your administration the potential dangers in delaying treatment for severe aortic disease patients?
Brian Whisenant, MD: Administration is an inherently receptive audience. Every day, they wonder what is around the corner. They survey, track, and share ventilator use, ICU capacity, and daily COVID trends in the state. As we move further into this, we recognize that we must have the capacity to be flexible and quickly change. As the hospital gives us more latitude to care for patients, we recognize that we must be ready to change quickly if necessary. They have been quite receptive.
Michael Reed, MD: It’s important to remember that patients, even before COVID, would sometimes die of their aortic stenosis waiting for TAVR, even with a normal progression of procedural execution. Delaying these patients for several months, certainly those we deem higher risk, is really like walking a tightrope. And our administrators understand that. They are supportive and respectful of the triage process that we are trying to develop as physicians, and we work very closely with them in communicating what cases we think should be done. We haven’t experienced any roadblocks. Everyone is working together, trying to do the right thing.
What about any changes in the assessment of patients prior to their TAVR? Dr. Whisenant, you are only performing angiography if you think the patient might be at high risk or doing so would change your management.
Brian Whisenant, MD: This is something we were doing even before the pandemic, recognizing that many patients are not great surgical candidates. Even if we find coronary disease, we are going to be inclined towards a percutaneous option for their coronary disease as well as their aortic stenosis. Unless the patient is quite low risk for surgery and high risk for coronary artery disease, then we look at their coronary arteries for the first time immediately before their TAVR in the same setting. We limit the number of times that patients come into the hospital. For example, if we have patients with a low flow, low-gradient aortic stenosis with a low dimensionless index, we agree to proceed with TAVR rather than bringing them in for an additional study. We do most of our consults remotely, often by phone. Our surgeon will sometimes see the patient on the morning of their TAVR without a second visit. Everything is quite streamlined to limit the number of contacts in the system.
Michael Reed, MD: We take it on a case-by-case basis. If a patient’s primary complaint is angina or they have renal insufficiency, it warrants minimizing the contrast dose at the time of TAVR, and we are more likely to do coronary angiography as a separate procedure. If they don’t have any angina and the TAVR computed tomography (CT) scan doesn’t show any proximal disease in the left main, proximal left anterior descending (LAD), or right coronary artery, then I feel comfortable doing the coronary angiogram at the time of TAVR. We are optimizing telehealth as best we can. Some of these patients really need to be seen in clinic, particularly to assess their functional status and to get a sense of their capability to undergo surgery versus TAVR. But for many of them, our initial intake is over the telephone or via telehealth, which has been a major change. I think telehealth is definitely going to be utilized more. Over 50% of our patients come from outside Missoula and they are driving from hours away to see us. They come, get a CT scan, and do a clinic visit and undergo a coronary angiogram, and then come again for a TAVR. It is a lot of driving back and forth, and we try to consolidate all those things. But now I think that we are going to be utilizing telehealth for one-month follow-up visits, for example, or if patients or family members have additional questions leading up to their procedures. The notion of performing the coronary angiogram at the time of TAVR will become a much more common practice just to minimize the number of times people have to come in. Those are two big changes.
How are you minimizing COVID-19 exposure for your patients?
Michael Reed, MD: All our patients wear masks coming into the hospital and during the procedure. They also wear masks while they are recovering. We certainly screen patients for COVID with certain standardized questions, and if there are any red flags in the screening, they will be tested prior to embarking on a procedure. Separating COVID patients from non-COVID patients is important. Other than that, common sense dictates that the less time our patients can spend in a hospital setting exposed to multiple people, the better. Whether that means combining their coronary angiogram with their TAVR, trying to expedite their discharge, or trying to see them in telehealth rather than in person, patients are very receptive to that idea.
Brian Whisenant, MD: We have a hospital policy of no visitors, which must be difficult for some patients, but I have been surprised that most patients do fine with it. We are good about calling family members before and after procedures, making sure that family members are updated on their family member’s progress and know how to reach us if they have questions. Communication is the key with patients — talking to them regularly and telling them that we want to make sure they are being cared for. If patients know our doors are open, that we are doing procedures, and that other patients are doing well and going home quickly, I think that builds confidence. All employees and healthcare providers wear masks in the hospital, and patients wear masks when they are outside of their rooms.
Michael Reed, MD: When the COVID pandemic first hit, there was a wave of fear that was astronomical, and as we have learned more about the prevalence of this virus in our country and the prevalence in our own individual communities, with time, people have been able to make more informed decisions about what are appropriate things to do and what aren’t. I am hopeful that the ability to triage procedures that are life-sustaining against the risk of exposure to the virus will become more informed with time and more refined. Both in the minds of the patients and the referring doctors, and in the minds of the operators.
Dr. Reed, can you share how you are utilizing same-day discharge for your TAVR patients?
Michael Reed, MD: This was an idea that came about just over the last month in speaking with other colleagues around the country. Our median length of stay for TAVR is one day, and we have been doing same-day discharge for elective percutaneous coronary intervention for almost a decade, so our recovery staff is familiar with the idea. We started thinking about identifying patients who would have a low risk for complications and who potentially could be discharged the same day. This process is based on, in some aspects, the fear that patients have with coming to the hospital for COVID and possibly staying in the hospital for a long period of time. Although that risk is low with TAVR, the idea of potentially discharging someone eight hours after their TAVR was appealing. One of the key questions is if someone doesn’t have any sign of complications at all at eight hours, such as hematoma or conduction delay on their EKG, how often are they going to develop those complications in the next 24 hours? If you have a low-risk patient and straightforward transfemoral TAVR, particularly if they have a pacemaker or they don’t have any conduction disturbance, they have a supportive family, and they are willing to spend the night locally, those are patients that potentially could be done as the first case, with an uncomplicated course, walking the halls and discharged eight hours after the procedure. We are starting to do this, and it has been really interesting working with patients and staff. I think same-day discharge is really going to make a big difference in our program. There are also indirect benefits from trying to mobilize patients early. If your focus is to try and get people up at four hours and the recovery staff is motivated to do that, even if patients don’t go home same day, they may be more likely to go home early the next day. We certainly have seen patients who sit in bed after their procedure and don’t get up at all the day of the procedure, and then they have urinary retention or maybe it’s just fatigue from lying in bed. And they stay another day in the hospital, just because they haven’t mobilized. So even if they don’t go home the same day, I do think early mobilization is a real priority, and outpatients would benefit from that, assuming it is done appropriately.
Dr. Whisenant, you have discharged some of your transcatheter mitral valve repair patients the same day, but not yet TAVR patients. Do you envision same-day discharge as something in the future for your TAVR patients?
Brian Whisenant, MD: I do. I think it will take more institutional discussion before everyone is completely comfortable. But for a young patient without conduction disease where we start early in the day and are done early, it makes a lot of sense. On very rare occasion, I can think of two or three patients who have asked for same-day discharge in the past who we have discharged (prior to COVID-19). So I can certainly see us doing that in the future on occasion and slowly escalating it. We have increased our use of the same-day recovery unit without ICU observation to keep our heart patients out of the ICUs.
Dr. Reed, can you talk more about the guidelines that you have put in place to identify patients who will go home with same-day discharge?
Michael Reed, MD: We are still early in this process, but we are using a standardized algorithm (Figure 1). Certainly pre procedure, it identifies patients who seem like they will have a straightforward transfemoral TAVR, and are without any obvious anatomic, cognitive, or practical limitations. Patients should have a supportive family who are going to spend the night locally and who are supportive. We have patients who are straightforward TAVR, but their family just doesn’t feel comfortable, and we honor their wishes. With regard to the procedure itself, we pay meticulous attention to vascular access. Not more than we normally would, but in a different way. Perhaps we use a radial access for the pigtail instead of second femoral access, and perhaps we pace the left ventricular wire rather than using a venous access with a balloon-tipped pacemaker. There are certain things you can attempt in order to minimize the impact of access. During the implant itself, attention to a higher implant may minimize the post-TAVR gradient, and minimize the risk of post-TAVR conduction delay or pacemaker. All these things, pre and peri procedure, are important. Probably the most important thing post procedure is setting the expectations with the recovery staff so that they know that in four hours, if there is no evidence of growing complications or conduction disease, and no red flags, the patients are expected to start walking the halls. If at eight hours, there are no electrical problems, no vascular problems, no cognitive issues, and all systems are a go, meaning the patient is walking the hall, feeling comfortable, and they have a supportive family living locally, then those are patients that potentially could go home at eight hours or stay in a hotel. We do provide them with a cellphone number of either the doctor on call or our valve coordinator on call. Then, if they have any questions that night, they can reach us directly. The next morning, we call them at 8:00 am to see how they are doing. Still, there are people who we intended to do as same-day discharge that ended up with some conduction delay after the TAVR and who stayed at the hospital overnight, as well as people whose family members have said, “Look, we live an hour away. Can we just have them spend the night at the hospital?” Same-day discharge is not something that we push on people, but there is a fraction of patients who are open to this idea. It is something that could be utilized to minimize their hospital length of stay and hopefully optimize their satisfaction overall. We are implanting in healthier patients now that low risk TAVR is approved, so we may identify a greater population.
Brian Whisenant, MD: I know patients love same-day discharge, but not all. The way Dr. Reed presented it is spot-on: making it an option for patients who are interested, and letting them know that we are going to make sure that they are comfortable, that they are not being pushed out the door, and that they have access to us. The most important thing is making sure patients understand they can reach us if they have concerns.
Can you tell us about how your heart team is working together during the pandemic?
Brian Whisenant, MD: Traditionally, we have had lots of hands-on meetings. We keep lists of patients on Excel spreadsheets and review them several times per week. Now that our volumes are less, we have just decreased the frequency that we meet. We have quite a few patients who were scheduled for some procedure that has been postponed because of our COVID-19 situation. I receive almost daily emails with patients who have been contacted with details of how they are doing, and who would like to talk to me. I call the patients who would like to talk to me, or when our advanced practitioners or nurses are concerned. Our team communicates regularly and is organized. We sometimes do video calls and sometimes sit in a conference room with masks while sitting far apart. But we are still trying to communicate regularly and make sure that we have a good handle on what is happening.
Michael Reed, MD: Our experience is similar. Less volume, but the practice hasn’t changed much. We have an outstanding team of nurse practitioners, nurses, and assistants who reach out to patients and communicate with us regularly as implanters. Our weekly valve meeting has changed in that we have now made it available via videoconference. We have a skeleton crew of people who are in the room at the table, and others maybe video conferencing in from home or from their office. We try and minimize the number of people in the room. So that’s one thing that has changed. The key is excellent communication and working together as a team.
How are you communicating with referring cardiologists?
Brian Whisenant, MD: We haven’t seen the same referrals that we were seeing before. Many of the cases that we have been doing have been patients transferred from an outside facility or admitted through the ER with acute heart failure. Referring physicians have questions about what we’re doing and what we can do. When we have a chance, we tell them that we are here to take care of patients and available, and invite them to call us.
Michael Reed, MD: It is a time of uncertainty about whether patients should be treated now or delayed, or whether patients should be transferred or optimized at an outside hospital, and then sent home, which is always a tough question. We do need to be reaching out more to our referring doctors and letting them know that we are still available. Figure 2 is an overview of our process for patient referrals during the COVID pandemic.
How do you think your program’s TAVR volume will be affected when the pandemic eases?
Brian Whisenant, MD: I don’t know that there is a magic button to turn everything back on, but patients are interested in their own healthcare. As they become short of breath and have other symptoms, we will see them. The whole country seems to be alarmed at the lack of cardiac procedures being done, realizing that patients’ health is being threatened. My sense is that we’re going to be doing a dance here for quite some time. Intermountain has different levels of availability: red, orange, yellow, and green. We may go in and out of these different levels. I anticipate that when we have more availability, we’ll treat as many patients as possible, and that there is pent-up demand. We will be prepared to scale back if we start seeing COVID-19 numbers rise. This may not happen, but we will be prepared.
Michael Reed, MD: I agree. It is going to be a systematic approach, starting with primary care providers and the general cardiologists at outside hospitals. We are at the end of the referral process when we finally meet the patients, but there is a great deal of work that needs to be done upstream in the primary care clinics and in the general cardiology offices to identify these patients and reassure them that if they have a gradually life-threatening problem, it shouldn’t be neglected. We are always trying to find that sweet spot of when to treat people now versus delay their care to minimize their risk of exposure. It is going to be a moving target.
Are there things that you are doing now that you think will continue as part of protocols or pathways going forward?
Michael Reed, MD: Telehealth is definitely going to be utilized more. More than 50% of our patients come from outside Missoula and are driving from hours away to see us and have a CT scan, clinic visit, and coronary angiogram, and then come again for a TAVR. It is a lot of driving back and forth, and we try and consolidate as best we can. I imagine that we are going to be utilizing telehealth for one-month follow-up visits, for example, or if patients or family members have additional questions leading up to their procedures. I also think the notion of performing the coronary angiogram at the time of TAVR will become a much more common practice, if only to minimize the number of times people have to come in.
Brian Whisenant, MD: I agree. We also have patients who come from a broad area. We do a good job of pre-screening them to make sure that their plan is very efficient and that their travel is minimized. I anticipate that we will continue to utilize the CCU less than we have in the past, which will be a positive outcome of this. We will look at same-day discharge more closely. We have limited some of our post-procedure steps such as routine echos and we have stopped doing post-procedure echos in stable patients who are doing well.
How can we get back on track with making sure that TAVR is accessible to patients that need it?
Brian Whisenant, MD: I worry that as patients have more virtual visits, their murmurs will not be detected and echos will not be performed. Trying to gear up the systems so that we appropriately identify and treat patients is going to take some discussion. No one knows what’s around the corner, so it is possible we are going to stay slow for a while. Most seemed to be on board with a several-week slowdown to see what happens. But already this week, patients seem to be anxious to be treated. I have seen a few more patients come in this week with things that I think they were staying home with last week.
Michael Reed, MD: There will be a backlog, particularly of coronary disease and heart failure patients that hadn’t been seeking care and may be experiencing symptoms that normally would have prompted them to seek care. This will also include elective procedures that turned out not to be so elective once you did the coronary angiogram and identified a critical left main. With regard to TAVR, we are lucky to have a system in place that facilitates regular communication with these patients. Our staff does a great job and I know that the staff around the country at every valve program is no different. Hopefully it will help provide a safety net for our aortic stenosis patients whose treatment has been delayed longer than normal. There is more insight in the public about the value of cardiac treatment. This is not elective, optional surgery. Aortic stenosis is a life-threatening problem. You leave it alone, it’s a mechanical obstruction that is ultimately fatal. So I really hope that we don’t let people slip through the cracks. I am confident in our system and I think that we are going to find a way to get these people treated.
Dr. Michael Reed can be contacted at email@example.com.
Dr. Brian Whisenant can be contacted at firstname.lastname@example.org.
Sponsored by Edwards Lifesciences • Cath Lab Digest June 2020, Vol. 28, No. 6 ©2020 HMP Global