June 10, 2020Open Access

Transcatheter management of severe aortic stenosis during the COVID-19 pandemic

Q: What is the clinical evidence from this study?

Study design: Review. Population: Severe aortic stenosis. Intervention: Transcatheter aortic valve implantation (TAVI) vs. Surgical aortic valve replacement (sAVR).

Key Result

Transcatheter aortic valve implantation is an effective treatment for severe aortic stenosis that minimizes hospital stay and critical care utilization compared to surgical replacement during the COVID-19 pandemic.

Structured PICO

How should the management and clinical pathways for severe aortic stenosis be adapted during the COVID-19 pandemic?

Population

Patients with severe symptomatic aortic stenosis during the COVID-19 pandemic

Intervention

Transcatheter aortic valve implantation (TAVI) and streamlined clinical pathways

Comparator

Surgical aortic valve replacement (sAVR) and standard pre-pandemic care pathways

During the COVID-19 pandemic, shifting severe aortic stenosis treatment toward TAVI and streamlining clinical pathways can preserve critical care capacity and protect vulnerable patients from nosocomial infection.

Limitations

Lack of robust long-term data on TAVI valve durability
Higher rates of paravalvular leak compared to surgery
Higher rates of permanent pacemaker implantation
Lower procedural success and higher complication rates in patients with bicuspid aortic valves

Abstract

### Learning objectives The current COVID-19 outbreak presents an unprecedented challenge to health services worldwide. With the primary goal of reducing the risk of spread of COVID-19, protecting patients and healthcare teams and preserving access to necessary/emergency care, the UK National Health Service (NHS) issued specialty guidance for the management of cardiology patients during this time.1 All hospital trusts were advised early to defer non-urgent cardiovascular diagnostics and interventions and from an early stage, virtually all cardiac surgery ceased, apart from emergency cases. Patient pathways were modified to ensure the highest risk patients could continue to access urgent cardiac care (eg, patients presenting with ST-elevation myocardial infarction (MI)). The underlying aim was to ensure that emergency services remained resilient throughout what was then an unknown onslaught. This guidance was tailored to subspecialty areas including heart failure, arrhythmia, coronary disease and valvular heart disease, in particular the management of aortic stenosis (AS). AS is common and affects patient groups particularly vulnerable to a poor outcome with COVID-19 infection, with an overall prevalence of clinically significant AS in those greater than 70 years approximately 1%–3%.2 Severe, symptomatic AS has a uniformly poor prognosis, with an estimated 1-year mortality of up to 40%,3 worse than many metastatic cancers. No medical therapy influences outcome, and the only available prognostic treatment is valve replacement/implantation.4 While surgical valve replacement (sAVR) was the treatment of choice for decades, transcatheter aortic valve implantation (TAVI) has become an increasingly safe and effective treatment option in patients at …

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