Clinical Research & Data, COVID-19, Protected PCI, Right Heart Failure
Activating Cath Labs for Emergent Procedures Amid COVID-19: Best Practices for STEMI and RV Dysfunction
As cath labs reopen to handle emergent procedures amid the COVID-19 pandemic, they must strike a balance between patient and staff safety and high-quality procedural care. In these 2 videos, Ehtisham Mahmud, MD, FACC FSCAI shares best practices for STEMI treatment while William O’Neill, MD, FACC focuses on right ventricular dysfunction.
In the first video, Dr. Mahmud, cardiovascular medicine division chief at UC San Diego, presents strategies for determining whether the cath lab should be activated for potential emergent STEMI cases. Since it is increasingly recognized in the “COVID era” that not all COVID-positive patients presenting with ST-segment elevations are having a STEMI, his strategies categorize patients into “COVID-19 positive/probable” and “COVID-19 possible” and then examine symptoms and ECG findings to help differentiate STEMI from COVID-19 myocarditis or other diagnoses. While primary PCI remains the recommended first-line therapy for emergent STEMI, he explains the need for appropriate PPE, including N-95 masks, for the entire cath lab team.
During this COVID-19 pandemic, Dr. Mahmud emphasizes that before patients are sent to the cath lab, they should be screened in the ED for COVID-19 (with ultrarapid COVID-19 testing, if available) and have true STEMI confirmed in the ED. At his institution, COVID-19 positive/probable patients are treated in a dedicated COVID-19 cath lab and then sent to a pre-arranged ICU isolation bed. Regardless of the COVID status of patients, all cath labs should employ universal use of PPE for aerosolized and droplet precautions in STEMI.
Dr. Mahmud also discusses recommendations for STEMI at referral (non-PCI) hospitals and concludes his video by sharing steps that UC San Diego has taken to restart cath lab services.
In the second video, Dr. William O’Neill, medical director, structural heart disease at Henry Ford Hospital in Detroit, describes how his institution was “deluged” with more than 2000 patients with COVID-19. He explains how a limited capacity for ECMO led to a decision not to use ECMO in any of the cath lab patients and how they were able to manage patients with a combination of right ventricular and left ventricular support.
Dr. O’Neill highlights discussions with collaborators in Wuhan, China, in which they reported very little left ventricular shock as a result of COVID. Instead, they reported microthrombi causing pulmonary hypertension and right ventricular dysfunction.
Dr. O’Neill then reviews data on right ventricular dysfunction from the National Cardiogenic Shock Initiative (NCSI) study, showing a very dramatic decrease in survival in patients with RV dysfunction. He highlights how to identify RV dysfunction using CVP/PCWP ratio and PAPI, and notes, “It’s really crucial to identify RV shock early and to treat it aggressively, and if you can treat it with support aggressively, I think you’re likely to have a much better recovery.”
Dr. O’Neill also emphasizes the importance of SmartAssist® technology that enables physicians at home to identify right ventricular dysfunction in patients supported with Impella®. He explains that with very aggressive identification of right ventricular dysfunction and the addition of right-sided Impella support, “we should be able to consistently get a survival of up to 80% in patients with acute MI shock.”
“This last 6 weeks has been a terror,” Dr. O’Neill states. “We are starting to open up our procedural platform. Next week we’re doing TAVRs, MitraClip™, and WATCHMAN™ devices…We’re really hoping that we finally are on the other side of this crisis.”