Indications for Procedures from the In-patient or Unstable Out-patient Setting
Prior to performing a procedure on patients from both the in- or out-patient setting, COVID testing is performed on all patients with the understanding that there may be false negative results. It is important to ensure sufficient standard PPE for procedures is identified ahead of time, as hospital resources diminish quickly. We have prioritized and performed due to their urgent/emergent nature: PPM for symptomatic, high-grade or wide-complex complete heart block (CHB), generator change for PPM-dependent patient with device nearing end of life (EOL), cardiac resynchronization therapy devices nearing EOL to prevent detrimental hemodynamic consequences, VT ablation in unstable/hospitalized patients with VT storm refractory to medication, accessory pathway ablation in pre-excited AF, and device/lead extraction in an unstable patient with active sepsis. We have also performed pacemakers immediately after urgent/emergent transcatheter aortic valve replacement with resultant heart block to facilitate discharge on the same day.
The expedition of urgent procedures for patients waiting in intensive care units (ICUs) is paramount. We have structured a multidisciplinary approach with intensive care unit (ICU) and nursing staff to facilitate performing procedures on extended weekday and weekend hours to minimize use of institutional resources and free up much-needed ICU beds for the growing COVID-19 patient population.
The more challenging decision involves semi-urgent indications for EP procedures such as secondary prevention ICD, primary prevention ICD in a very high-risk patient (i.e. ischemic heart disease with nonsustained VT, muscular dystrophy or sarcoid), or lead revision/replacement in the setting of malfunction/dislodgment in patients who are currently or imminently will be hospitalized. It may be necessary to rely on a wearable defibrillator (LifeVest, Zoll, Chelmsford, MA) for the secondary prevention patient population until the inflection point of COVID-19 cases is reached and transmission risk is lower. Furthermore, maximal medication management has been implemented for patients with symptomatic, recurrent SVT at the current time. Alternatively, these procedures must be evaluated and performed on an individual case-by-case basis to weigh risk versus benefit from the procedure. If it is decided that cardiovascular benefit outweighs the risk, then scheduling the patient for the earliest daytime slot possible to facilitate same-day discharge is advisable. Coordination with infectious disease (ID) prevention and control colleagues is also essential.