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Pandemic AVR: Making Patients Wait May Do More Harm Than Good

Recent cardiac events suffered by patients with symptomatic severe aortic stenosis (AS) could be tied to whether their hospitals expedited aortic valve replacement (AVR) in select cases or paused these procedures in response to COVID-19, two reports suggested.

In the first, a Swiss hospital showed success selecting patients for expedited AVR despite safety concerns during the pandemic, whereas a New York City center that pushed these procedures back for everyone had a substantial number of patients subsequently die or require urgent transcatheter AVR (TAVR) while waiting, the second found.

Both reports were published online in JAMA Network Open.

“Taken together, these studies provide useful guidance. First, as we have known for many years, symptomatic AS is a life-threatening condition, and its treatment cannot be considered elective in any way. Patients with the most echocardiographically severe stenosis, clinically advanced symptoms, or comorbid coronary artery disease or lung disease belong at the head of the line,” according to Thoralf Sundt, MD, of Massachusetts General Hospital and Harvard Medical School in Boston.

“Whether one chooses to interpret the current state of the pandemic as an ongoing first wave — perhaps with a nadir in some regions — or as the quiet before a second wave, there is a clear need for tools permitting precise triage of patients by the urgency with which procedures should be performed,” he emphasized in an accompanying editorial.

Selective AVR in Switzerland

Certain people with critical AS were good candidates for expedited AVR during a nationwide ban on elective procedures, according to the prospective AS DEFER study.

A cohort of 71 patients referred for AVR from March 20 to April 26, a period when Switzerland banned elective procedures in all hospitals, were divided into two treatment groups according to a prespecified algorithm:

  • Expedited (n=25): Patients with critical AS (i.e., aortic valve area ≤0.6 cm2, transvalvular mean gradient ≥60 mm Hg, cardiac decompensation during the previous 3 months, or exercise intolerance with clinical symptoms on minimal exertion) who underwent TAVR at a mean 10 days after referral
  • Deferred (n=46): Patients with a larger aortic valve area and stable symptoms

Adverse cardiac outcomes were not statistically more likely for either group at an average 31 days after treatment allocation: the composite endpoint of all-cause mortality, disabling and nondisabling stroke, and unplanned hospitalization for valve-related symptoms or worsening heart failure reached 4.0% of the expedited group versus 19.6% of those deferred (log rank P=0.08), reported Thomas Pilgrim, MD, MSc, of Inselspital, Bern University Hospital, and colleagues.

Hospitalizations were more likely in the deferred AVR arm than the expedited arm (19.6% vs 0.%, P=0.02) and accounted for all the primary outcome events in the former. No patient died.

Among deferred AVR patients, those who wound up requiring hospitalization for valve-related symptoms or worsening heart failure had more commonly presented with multivalvular disease (44.4% vs 8.6%, P=0.02), suggesting that this group in particular may benefit from expedited AVR, Pilgrim’s group said.

“I cannot tell if the authors considered