Restructuring needed to combat backlog of interventional procedures due to pandemic
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Excess CV mortality due to the pandemic has been observed globally, and clinicians may need to consider restructuring services to meet the backlog of patients on the waiting list to undergo lifesaving interventions, a speaker reported.
At the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions, Mamas A. Mamas, DPhil, MRCP, professor of cardiology of the Keele Cardiovascular Research Group at Keele University in Staffordshire, U.K., discussed some of the trends in CV admissions during the pandemic and what interventionalists may need to do to combat the growing backlog of elective and lifesaving procedures, particularly those for severe aortic stenosis.
Studies in northern Italy, New York and England all reported drops in admission and management of ACS during the pandemic period, as well as lower daily admissions for HF and MI.
In a paper published in Circulation: Cardiovascular Interventions, Mamas and colleagues also reported large reductions in PCI activity in the U.K., with a 40% drop in PCI procedures and an 80% decline in elective PCIs after the U.K. implemented a lockdown.
According to the presentation, clinicians in the U.K., began seeing a drop in STEMI activity as early as February 2020, despite the lockdown not beginning until March 10.
During the U.K. lockdown, the health secretary issued a requirement that all NHS Trust hospitals cease any elective procedures, with the goal of increasing capacity for ventilation and emergencies, Mamas said.
“We’ve also looked at aortic stenosis, whether it be treated by surgical [aortic valve replacement] or [transcatheter aortic valve replacement], and again, marked reductions in activity during the COVID-19 pandemic,” Mamas said. “As far as November, we still have not seen a return to activity that we had pre-pandemic or what would be predicted.”
According to the presentation, from March to November 2020, researchers estimated that 4,989 individuals (95% CI, 4,020-5,959) in England with severe aortic stenosis did not receive treatment. Of these cases, it was estimated that 99 to 698 patients died while waiting for intervention.
To evaluate this issue further, Mamas and colleagues collaborated with mathematicians at the University of Cambridge and the University of Bristol to develop a report, “Modeling Solutions to the Impact of COVID-19 on Cardiovascular Waiting Lists.” The report detailed potential solutions to addressing the backlog of patients with severe aortic stenosis who did not yet receive surgical AVR or TAVR.
For this report, researchers assumed there was 40% mortality rate at 1 year for untreated severe aortic stenosis (0.15% per day); there was a 5,000-patient backlog; that referrals would be similar to the pre-COVID-19 era; and there was similar surgical AVR and TAVR capacity to the pre-COVID-19 era.
The mathematical modeling predicted the following:
- If interventionalists make no changes, there will still be a waiting list at 3 years, and 5,000 deaths will need to occur to clear the backlog.
- If interventionalists move to 7 workdays per week, the backlog may be cleared at 500 days, with 1,700 deaths among those on the waiting list.
- If patients with severe aortic stenosis initially intended to undergo surgical AVR are diverted to TAVR, but there is no change in work schedule, the backlog may be cleared after 1 year with 1,100 deaths of people on the waiting list.
- If physicians work 7 day per week and divert those intended for surgical AVR to TAVR, the backlog may be cleared at 200 days, with 700 deaths among patients on the waiting list.
“Clearly we need to change our working practices and we need to change the threshold by which we treat patients either with surgical AVR or TAVR,” Mamas said.
“There is an urgent need to reconsider structuring services to meet this backlog, and if we don’t, we’re going to have large mortalities,” Mamas said during the presentation. “We’ve seen in the U.K. excess CV mortality in the community, and that partly relates to patients staying at home ... but also our failure to be able to deliver CV interventions in a timely manner.”
References:
- Isaac Newton Institute. Modeling Solutions to the Impact of COVID-19 on Cardiovascular Waiting Lists. https://gateway.newton.ac.uk/event/tgmw90. Accessed May 6, 2021.
- Kwok CS, et al. Circ Cardiovasc Interv. 2020;doi:10.1161/CIRCINTERVENTIONS.120.009654.
- Martin GP, et al. medRxiv (preprint). 2021;doi:10.1101/2020.08.05.20168922.
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Mamas M. COVID-19 in 2021: Interventional Perspectives. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 28-May 1, 2021 (virtual meeting).
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