Impact of the COVID-19 pandemic on transcatheter aortic valve implantation in Spain

To the Editor,

The current COVID-19 pandemic has changed our health system dramatically. The need to have resources available to assist the high volume of patients affected, the healthcare overload, and the need to limit exposure to the virus have led to the implementation of extraordinary measures like delaying the healthcare provided to patients with chronic conditions and the almost total suspension of elective procedures such as the transcatheter aortic valve implantation (TAVI).1

The Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) sent a survey to the hospitals included in the Spanish TAVI registry with the following objectives: quantify the temporal damage caused by the COVID-19 pandemic to TAVI procedures in our country, analyze the disease progression of patients not treated because of the pandemic, study the rate and consequences of the infection in patients treated during this period of time, and ultimately assess the number of COVID-19 infections within the medical staff of the cath labs. Forty out of the 46 centers included in the national registry participated in the study (86.9%). The parameters of thid survey are shown on figure 1.

Figure 1. Survey sent to the participating centers.

From January 1 to April 30, 2020, 890 TAVIs were performed. Most of them (813 out of the 890, 91.4%) until the first 2 weeks of March, and only 77 (8.6%) since the state of alarm was declared, which is a 95% drop in the activity developed. If we take 2 comparable time periods before and after the declaration of the state of alarm—the month of February and the first 2 weeks of March 2020 vs the second 2 weeks of March and the month of April—the drop is still very significant: 509 TAVIs vs 77 TAVIs (an 86.9% drop) (figure 2). After TAVI, 18 patients (2.0%) died at the hospital, most of them of cardiovascular causes (16/18, 88.9%). During admission, 7 patients (0.8%) contracted the virus, all of them between the months of February and March, and most of these infections occurred before the declaration of the state of alarm (6 vs 7; 85.7%). Two of these patients died. Therefore, in February and within the first 2 weeks of March, the rate of nosocomial COVID-19 was 1.2%, lethality was 33.3%, and mortality rate due to nosocomial COVID-19 was 0.4%. During the state of alarm, only 1 of these 77 patients treated with TAVI had nosocomial COVID-19. This patient ended up dying (rate of nosocomial COVID-19 and mortality rate due to nosocomial COVID-19 of 1.3%). There are data available of the waiting lists of 37 of the 40 participating centers. Back in March 1, 2020, 810 patients were waiting to receive their implants. Twenty-four (2.9%) patients died while on the waiting list within the following 2 months (until April 30). Most deaths (20 out of the 24; 83.3%) were due to aortic valve disease and 4 (16.7%) to COVID-19 infection. Another 4 patients (0.5%) required an emergency TAVI, had no complications, and a favorable progression after the procedure. Therefore, 28 patients (3.5%) died while on the waiting list or required an emergency TAVI. Finally, 15 (6.9%) out of the 217 interventional cardiologists from the cath labs of the participating centers tested positive for COVID-19 in the polymerase chain reaction tests performed.

Figure 2. Temporal evolution of transcatheter aortic valve implantation (TAVI) in relation to the incidence of COVID-19 in Spain.

The national registry shows a significant reduction in the number of percutaneous coronary interventions performed to treat aortic valve disease since the COVID-19 pandemic was declared in our country. The risk of nosocomial infection and healthcare overload added to the risk associated with postponing these procedures2,3 make it necessary to keep a follow-up and individualized assessment of every patient to be able to prioritize the indications.4 A practical consequence of these data is that the patients’ mortality rate while on the waiting list was clearly higher (3%) compared to the mortality rate due to nosocomial COVID-19 (1.3%). This may lead to the need of having to keep TAVI programs if logistically possible in future pandemics we may encounter. Finally, it is essential to guarantee the adequate protection of patients to avoid nosocomial infections that may be life-threatening and provide individual protection equipment (IPE) to the healthcare professionals who may be exposed to infections.5

CONFLICTS OF INTEREST

The authors declared no conflicts of interest in relation to this manuscript. R. Moreno is associate editor of REC: Interventional Cardiology; the journal’s editorial procedure to ensure impartial handling of the manuscript has been followed.

Annex. Participanting hospitals and principal investigator in each center

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