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.