Primary Percutaneous Coronary Intervention during the COVID-19 Pandemic

    Authors

    DOI

    https://doi.org/10.15836/ccar2020.91

    Full Text

    ## Global experiences The COVID-19 virus pandemic represents a massive challenge to national healthcare systems. Given the characteristics of the virus, such as its virulence, i.e. its ability to spread infection in the asymptomatic phase, its rapid spread in enclosed environments, especially in healthcare institutions, and its pathogenicity, i.e. the high number of patients who require hospital treatment and the relatively high ratio of patients that require intensive care, critical care capacities in countries with large-scale epidemics of the virus have been almost completely occupied by patients with COVID-19 infection. Controlling the epidemic requires rigorous measures in the general population but even more aggressive measure within the healthcare system. Care for patients with indications for primary percutaneous coronary intervention (pPCI) can be facilitated by experiences from our colleagues in China as well as Italy and Slovenia as being countries in which the organization of the healthcare system is similar to ours. Zeng et al published a letter to the Editor in the Intensive Care Medicine journal describing the protocol for the treatment of acute coronary syndrome in patients positive for COVID-19 or suspected to have the virus ( 1 ). Fibrinolysis was reported to be the preferred reperfusion method in such patients with acute myocardial infarction ST elevation (STEMI) on the ECG, with percutaneous coronary intervention (PCI) used only in patients after failed fibrinolysis, and even then only in those with mild pneumonia or contraindications for fibrinolysis. In other words, the benefits of the interventional procedure must significantly outweigh the risk of spreading the infection. In non-ST-segment elevation myocardial infarction (NSTEMI), PCI is recommended after curing the pneumonia, i.e. the respiratory system infection caused by COVID-19. However, opinions of Western authors differ in comparison with Chinese authors. Welt et al commented on the recommendations of the Chinese authors in JACC from the perspective of a healthcare system with widely available pPCI and suggested a more liberal approach, i.e. they do not recommend giving up on providing optimal reperfusion strategy despite organizational issues ( 2 ). They suggest considering fibrinolysis as the therapy of choice in stable patients with active COVID-19 infection (without further elaboration), but they recommend individual assessment of the benefits of the procedure given the risk of exposing healthcare personnel to infection. They emphasize protection of healthcare workers during PCI procedures using protective gear that includes N95 masks, coveralls, and goggles or face shields. After the intervention is complete the cardiac catheterization lab should be thoroughly disinfected, especially considering that such labs are unfortunately almost always equipped only with normal ventilation systems without negative pressure capability. The authors suggest that early intubation should be performed in the ward/critical care before the PCI procedure, and if indicated to avoid procedures that generate aerosols in the laboratory. Direct communication with colleagues from the Ljubljana University Medical Centre showed their patients suspected to have COVID-19 were not denied pPCI. A swab was taken from these patients as soon as they arrived at the lab, pPCI was performed with all the protective measures against infection, and the patient remained in the “grey zone” (an isolated area, possibly as part of the lab, but with monitoring appropriate for coronary syndrome) until arrival of the test results. Patients who required mechanical circulatory support waited for the swab results in an isolated part of the intensive care unit. Further patient procedures depend on the swab results, and the decision is made as a team and individually for each patient based on available personnel and hospital capacity, while applying all the possible measures to protect hospital staff and other patients from infection. The current state of the Croatian Primary Percutaneous Coronary Interventions Network Heads of laboratories included in the Croatian Primary Percutaneous Coronary Interventions Network were polled by phone ( 3 ), showing that all cardiac catheterization labs outside Zagreb and central Croatia are continuing normal treatment for patients with acute coronary syndrome but with significant or complete reduction of the elective program. The situation is also similar at the Magdalena Clinic for Cardiovascular Diseases. Most labs have introduced and implemented the previously mentioned protocols recommended by foreign authors, but some colleagues have complained about the initial lack of specific protective gear for treating patients with COVID-19 and the lack of education on its use. In addition to the COVID-19 pandemic, the situation in cardiac catheterization labs in Zagreb was further complicated by the earthquake that took place on March 22, 2020. Due to having to place a number of physicians and nurses in isolation, the University Hospital Centre (UHC) Zagreb was forced to reduce its intervention program to directly hospitalized patients with NSTEMI for a period of two weeks, whereas pPCI was practically no longer conducted for STEMI patients until March 27, 2020, especially from the relevant counties. The situation has now changed and the UHC Zagreb has returned to the Croatian pPCI Network taking over both its own patients and the patients who gravitate to the University Hospital (UH) Dubrava. Given that the UH Dubrava has, along with the Zagreb University Hospital for Infectious Diseases, been strategically selected as the care center for patients COVID-19, according to current information the University Hospital is not able to provide PCI services for the time being. It is not currently clear whether the physicians and staff of the cardiac catheterization lab in that hospital will be engaged somewhere else in service of the Croatian pPCI Network or if they will be mobilized solely for treating patients with COVID-19. Given the circumstances, the Laboratory at the UHC “Sestre milosrdnice” has temporarily taken over emergency interventional treatment for all patients who gravitate towards the UHC Zagreb and UH Dubrava as well as the area covered by the UHC “Sestre milosrdnice” itself, both in Zagreb and other counties. Unfortunately, the earthquake of March 22 severely damaged the building that houses the Cardiac Catheterization Lab of the UHC “Sestre milosrdnice”. The lab was closed due to danger of building collapse after a preliminary building safety inspection on the day of the earthquake, but a conclusive building safety inspection on March 25 approved recommencement of work in the building and the center was returned to pre-earthquake levels of activity. Between March 22 and March 25 this year, all patients with STEMI and hemodynamically unstable NSTEMI for whom these three institutions were responsible as well as patients under the responsibility of the city of Zagreb and the Zagreb County were treated at the UH “Sveti Duh” under the 24/7 system, whereas the Cardiac Catheterization Laboratory at the UH “Merkur” took over patients with NSTEMI from the UHC “Sestre milosrdnice” as well as from other institutions with which it has established cooperation, but only during regular working hours. Since March 25 these two centers returned to regular activity regarding interventional treatment of acute coronary syndrome. Help in caring for patients with acute myocardial infarction under the 24/7 system was also offered by the Čakovec County Hospital (especially to the Varaždin County and Koprivnica-Križevci County) and the Magdalena Clinic, and the Agram Special Hospital also offered to help within its means. Further dynamic reorganization of activity and jurisdiction with be greatly dependent on the dynamics of the epidemic and its spread, the material resources and personnel required for its treatment, and on resolving the issues in the work of the cardiac catheterization labs of the aforementioned clinical institutions in Zagreb. We would like to note that professional societies like the Croatian Cardiac Society have an advisory role in such situations and that final decisions are made by the Ministry of Health of the Republic of Croatia and the directors of the relevant healthcare institutions. The cardiological community will receive timely notifications on all future changes in the functioning of the Croatian pPCI Network. ## Conclusion and recommendations for further activity The conclusions we can draw based on experiences with the COVID-19 pandemic so far are the necessity of rationally selecting patients for interventional cardiologic treatment, acquisition of all necessary protective gear and their proper use by cardiological teams working with infected or potentially infected patients, creating protocols for working with these patients in cardiac catheterization labs and after intervention, and forming both active and reserve cardiological teams that guarantee uninterrupted work in case of infection or suspected infection among members of the currently active team. Until further notice, we recommend that all patients with suspected COVID-19 infection are tested immediately and that they, along with patients positive for COVID-19, receive pPCI only in case of STEMI or hemodynamical instability in NSTEMI. The precondition for emergency interventions in such patients is adequate protection for the staff of the cardiac catheterization lab as well as other personnel that will be in contact with these patients. Until the test results for COVID-19 arrive, these patients should be closely monitored and treated in an isolated environment, and the whole staff in contact with the patient must be optimally protected. If the patient is positive for COVID-19, they are to be transferred to a COVID hospital, and if the patient is negative they should be transferred to intensive cardiac care at the appropriate hospital ( Figure 1 , Figure 2 ). Postupnik za hitnu perkutanu koronarnu intervenciju u bolesnika pozitivnih ili suspektnih na infekciju virusom COVID-19. *Klinička bolnica Dubrava za Zagreb i sjeverozapadnu Hrvatsku PCI – perkutana koronarna intervencija; KB – klinička bolnica; katlab – laboratorij za kateterizaciju; OHBP = objedinjeni hitni bolnički prijam. Protocol for emergency percutaneous intervention in patients positive or suspected of COVID-19 infection. *University Hospital Dubrava for Zagreb and northwestern Croatia PCI = percutaneous coronary intervention; UH = University Hospital; cath lab = cardiac catheterization lab; ER = emergency room. In case of STEMI and pPCI being impossible to perform under the conditions described above, fibrinolysis should be applied according to current guidelines ( 4 ) as an alternative to pPCI. Due to the risk of infection, it is likely that fibrinolysis will be the therapy of choice for most patients positive for COVID-19 but also for those in whom infection is suspected, especially if emergency PCI requires transport from the county hospital to a PCI center. In case of unsuccessful fibrinolysis, rescue PCI can be considered, after which the patient is generally transferred to a COVID hospital. Patients with suspected COVID-19 infection or those positive for the virus who are suffering from acute coronary syndrome and have indication for mechanical support should be treated in an isolated area of the coronary care unit or the cardiac catheterization lab, with appropriate protective measures for medical staff. If the test is positive, the patient should be transferred to a COVID hospital after introduction of mechanical support and should be treated in the current hospital if transport is not possible. Patients with NSTEMI should be treated in hospitals to which they belong according to territorial division. Indications for invasive procedures are to be established individually, based on risk and disease severity and in consultation with the responsible interventional center. Patients with established or suspected COVID-19 infection should be considered for invasive treatment only in case of hemodynamic instability or symptoms refractory to medication therapy. PCI and postinterventional care should be performed under the conditions and recommendations for STEMI that have been described above. Other patients with NSTEMI should be treated conservatively until they are negative for COVID-19. Finally, it should be emphasized that the decision on applying acute interventional treatment should be based on the condition of the patient, estimated benefit from PCI and infection risk, and the availability of appropriate protection for medical staff and other patients, and should be made individually for every patient and under full authority and responsibility of the interventional team responsible for their treatment. The coauthors would like to thank Marin Pavlov, the Secretary of the Working Group for Acute Coronary Syndrome of the Croatian Cardiac Society for his help in the writing of this text. Follow the article updates at www.kardio.hr

    Cardiologia Croatica
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    Primary Percutaneous Coronary Intervention during the COVID-19 Pandemic

    Special Article
    Issue5-6
    Published
    Pages91-96
    PDF via DOIhttps://doi.org/10.15836/ccar2020.91

    Authors

    Zdravko BabićORCIDCroatian Cardiac Society, Croatia
    Eduard MargetićORCIDCroatian Cardiac Society, Croatia
    Davor Miličić*ORCIDCroatian Cardiac Society, Croatia

    Full Text

    ## Global experiences The COVID-19 virus pandemic represents a massive challenge to national healthcare systems. Given the characteristics of the virus, such as its virulence, i.e. its ability to spread infection in the asymptomatic phase, its rapid spread in enclosed environments, especially in healthcare institutions, and its pathogenicity, i.e. the high number of patients who require hospital treatment and the relatively high ratio of patients that require intensive care, critical care capacities in countries with large-scale epidemics of the virus have been almost completely occupied by patients with COVID-19 infection. Controlling the epidemic requires rigorous measures in the general population but even more aggressive measure within the healthcare system. Care for patients with indications for primary percutaneous coronary intervention (pPCI) can be facilitated by experiences from our colleagues in China as well as Italy and Slovenia as being countries in which the organization of the healthcare system is similar to ours. Zeng et al published a letter to the Editor in the Intensive Care Medicine journal describing the protocol for the treatment of acute coronary syndrome in patients positive for COVID-19 or suspected to have the virus ( 1 ). Fibrinolysis was reported to be the preferred reperfusion method in such patients with acute myocardial infarction ST elevation (STEMI) on the ECG, with percutaneous coronary intervention (PCI) used only in patients after failed fibrinolysis, and even then only in those with mild pneumonia or contraindications for fibrinolysis. In other words, the benefits of the interventional procedure must significantly outweigh the risk of spreading the infection. In non-ST-segment elevation myocardial infarction (NSTEMI), PCI is recommended after curing the pneumonia, i.e. the respiratory system infection caused by COVID-19. However, opinions of Western authors differ in comparison with Chinese authors. Welt et al commented on the recommendations of the Chinese authors in JACC from the perspective of a healthcare system with widely available pPCI and suggested a more liberal approach, i.e. they do not recommend giving up on providing optimal reperfusion strategy despite organizational issues ( 2 ). They suggest considering fibrinolysis as the therapy of choice in stable patients with active COVID-19 infection (without further elaboration), but they recommend individual assessment of the benefits of the procedure given the risk of exposing healthcare personnel to infection. They emphasize protection of healthcare workers during PCI procedures using protective gear that includes N95 masks, coveralls, and goggles or face shields. After the intervention is complete the cardiac catheterization lab should be thoroughly disinfected, especially considering that such labs are unfortunately almost always equipped only with normal ventilation systems without negative pressure capability. The authors suggest that early intubation should be performed in the ward/critical care before the PCI procedure, and if indicated to avoid procedures that generate aerosols in the laboratory. Direct communication with colleagues from the Ljubljana University Medical Centre showed their patients suspected to have COVID-19 were not denied pPCI. A swab was taken from these patients as soon as they arrived at the lab, pPCI was performed with all the protective measures against infection, and the patient remained in the “grey zone” (an isolated area, possibly as part of the lab, but with monitoring appropriate for coronary syndrome) until arrival of the test results. Patients who required mechanical circulatory support waited for the swab results in an isolated part of the intensive care unit. Further patient procedures depend on the swab results, and the decision is made as a team and individually for each patient based on available personnel and hospital capacity, while applying all the possible measures to protect hospital staff and other patients from infection. The current state of the Croatian Primary Percutaneous Coronary Interventions Network Heads of laboratories included in the Croatian Primary Percutaneous Coronary Interventions Network were polled by phone ( 3 ), showing that all cardiac catheterization labs outside Zagreb and central Croatia are continuing normal treatment for patients with acute coronary syndrome but with significant or complete reduction of the elective program. The situation is also similar at the Magdalena Clinic for Cardiovascular Diseases. Most labs have introduced and implemented the previously mentioned protocols recommended by foreign authors, but some colleagues have complained about the initial lack of specific protective gear for treating patients with COVID-19 and the lack of education on its use. In addition to the COVID-19 pandemic, the situation in cardiac catheterization labs in Zagreb was further complicated by the earthquake that took place on March 22, 2020. Due to having to place a number of physicians and nurses in isolation, the University Hospital Centre (UHC) Zagreb was forced to reduce its intervention program to directly hospitalized patients with NSTEMI for a period of two weeks, whereas pPCI was practically no longer conducted for STEMI patients until March 27, 2020, especially from the relevant counties. The situation has now changed and the UHC Zagreb has returned to the Croatian pPCI Network taking over both its own patients and the patients who gravitate to the University Hospital (UH) Dubrava. Given that the UH Dubrava has, along with the Zagreb University Hospital for Infectious Diseases, been strategically selected as the care center for patients COVID-19, according to current information the University Hospital is not able to provide PCI services for the time being. It is not currently clear whether the physicians and staff of the cardiac catheterization lab in that hospital will be engaged somewhere else in service of the Croatian pPCI Network or if they will be mobilized solely for treating patients with COVID-19. Given the circumstances, the Laboratory at the UHC “Sestre milosrdnice” has temporarily taken over emergency interventional treatment for all patients who gravitate towards the UHC Zagreb and UH Dubrava as well as the area covered by the UHC “Sestre milosrdnice” itself, both in Zagreb and other counties. Unfortunately, the earthquake of March 22 severely damaged the building that houses the Cardiac Catheterization Lab of the UHC “Sestre milosrdnice”. The lab was closed due to danger of building collapse after a preliminary building safety inspection on the day of the earthquake, but a conclusive building safety inspection on March 25 approved recommencement of work in the building and the center was returned to pre-earthquake levels of activity. Between March 22 and March 25 this year, all patients with STEMI and hemodynamically unstable NSTEMI for whom these three institutions were responsible as well as patients under the responsibility of the city of Zagreb and the Zagreb County were treated at the UH “Sveti Duh” under the 24/7 system, whereas the Cardiac Catheterization Laboratory at the UH “Merkur” took over patients with NSTEMI from the UHC “Sestre milosrdnice” as well as from other institutions with which it has established cooperation, but only during regular working hours. Since March 25 these two centers returned to regular activity regarding interventional treatment of acute coronary syndrome. Help in caring for patients with acute myocardial infarction under the 24/7 system was also offered by the Čakovec County Hospital (especially to the Varaždin County and Koprivnica-Križevci County) and the Magdalena Clinic, and the Agram Special Hospital also offered to help within its means. Further dynamic reorganization of activity and jurisdiction with be greatly dependent on the dynamics of the epidemic and its spread, the material resources and personnel required for its treatment, and on resolving the issues in the work of the cardiac catheterization labs of the aforementioned clinical institutions in Zagreb. We would like to note that professional societies like the Croatian Cardiac Society have an advisory role in such situations and that final decisions are made by the Ministry of Health of the Republic of Croatia and the directors of the relevant healthcare institutions. The cardiological community will receive timely notifications on all future changes in the functioning of the Croatian pPCI Network. ## Conclusion and recommendations for further activity The conclusions we can draw based on experiences with the COVID-19 pandemic so far are the necessity of rationally selecting patients for interventional cardiologic treatment, acquisition of all necessary protective gear and their proper use by cardiological teams working with infected or potentially infected patients, creating protocols for working with these patients in cardiac catheterization labs and after intervention, and forming both active and reserve cardiological teams that guarantee uninterrupted work in case of infection or suspected infection among members of the currently active team. Until further notice, we recommend that all patients with suspected COVID-19 infection are tested immediately and that they, along with patients positive for COVID-19, receive pPCI only in case of STEMI or hemodynamical instability in NSTEMI. The precondition for emergency interventions in such patients is adequate protection for the staff of the cardiac catheterization lab as well as other personnel that will be in contact with these patients. Until the test results for COVID-19 arrive, these patients should be closely monitored and treated in an isolated environment, and the whole staff in contact with the patient must be optimally protected. If the patient is positive for COVID-19, they are to be transferred to a COVID hospital, and if the patient is negative they should be transferred to intensive cardiac care at the appropriate hospital ( Figure 1 , Figure 2 ). Postupnik za hitnu perkutanu koronarnu intervenciju u bolesnika pozitivnih ili suspektnih na infekciju virusom COVID-19. *Klinička bolnica Dubrava za Zagreb i sjeverozapadnu Hrvatsku PCI – perkutana koronarna intervencija; KB – klinička bolnica; katlab – laboratorij za kateterizaciju; OHBP = objedinjeni hitni bolnički prijam. Protocol for emergency percutaneous intervention in patients positive or suspected of COVID-19 infection. *University Hospital Dubrava for Zagreb and northwestern Croatia PCI = percutaneous coronary intervention; UH = University Hospital; cath lab = cardiac catheterization lab; ER = emergency room. In case of STEMI and pPCI being impossible to perform under the conditions described above, fibrinolysis should be applied according to current guidelines ( 4 ) as an alternative to pPCI. Due to the risk of infection, it is likely that fibrinolysis will be the therapy of choice for most patients positive for COVID-19 but also for those in whom infection is suspected, especially if emergency PCI requires transport from the county hospital to a PCI center. In case of unsuccessful fibrinolysis, rescue PCI can be considered, after which the patient is generally transferred to a COVID hospital. Patients with suspected COVID-19 infection or those positive for the virus who are suffering from acute coronary syndrome and have indication for mechanical support should be treated in an isolated area of the coronary care unit or the cardiac catheterization lab, with appropriate protective measures for medical staff. If the test is positive, the patient should be transferred to a COVID hospital after introduction of mechanical support and should be treated in the current hospital if transport is not possible. Patients with NSTEMI should be treated in hospitals to which they belong according to territorial division. Indications for invasive procedures are to be established individually, based on risk and disease severity and in consultation with the responsible interventional center. Patients with established or suspected COVID-19 infection should be considered for invasive treatment only in case of hemodynamic instability or symptoms refractory to medication therapy. PCI and postinterventional care should be performed under the conditions and recommendations for STEMI that have been described above. Other patients with NSTEMI should be treated conservatively until they are negative for COVID-19. Finally, it should be emphasized that the decision on applying acute interventional treatment should be based on the condition of the patient, estimated benefit from PCI and infection risk, and the availability of appropriate protection for medical staff and other patients, and should be made individually for every patient and under full authority and responsibility of the interventional team responsible for their treatment. The coauthors would like to thank Marin Pavlov, the Secretary of the Working Group for Acute Coronary Syndrome of the Croatian Cardiac Society for his help in the writing of this text. Follow the article updates at www.kardio.hr