Case Review, Complete Revascularization, COVID-19, Patient Management
COVID-19 Cath Lab Insights from Jeffrey Moses, MD at Columbia
Jeffrey Moses, MD, provides insights into cardiac cath lab challenges during and following the initial COVID-19 spike in New York. A key challenge at Columbia University Medical Center (CUMC) at the height of COVID-19 was how to determine which patients to bring to the cath lab amidst the confusing presentations with COVID-19. Needing a method for differentiating true STEMI from STEMI mimics (COVID-related myocarditis, stress induced cardiomyopathy, or other etiologies) with no culprit lesions, he explains how they focused on EKG features, “predominantly ST elevations in multiple territories with PR depression and the absence of reciprocal EKG changes,” and point of care ultrasound (POCUS) to triage patients.
Dr. Moses presents 2 clinical vignettes, both highlighting patient challenges in the COVID era. The first case, a 65 year old woman with metabolic derangement, led Dr. Moses to note, “It would be very difficult to walk away from this one and not bring it to the cath lab, especially when you look at the numbers that we have.” Hemodynamics from the right heart cath were indicative of right ventricular shock. She was found to have a massive thrombus in the right system and was treated with thrombectomy and eventually right-sided mechanical support with Impella RP®. The second case Dr. Moses describes represents the collateral damage seen with delayed presentation during the pandemic.
Dr. Moses discusses other patient challenges including the dilemma of whether there are really any “elective patients.” He explains that at CUMC they tried to use the “2-week criteria”—Is this patient in danger within the next 2 weeks?—to triage patients. His institution also worked on minimizing hospital stay with many same day discharges and ancillary testing done on an outpatient basis.
With regard to optimizing outcomes and resources in the COVID-19 era, Dr. Moses presents guidelines from SCAI and Impella® data demonstrating that initiating Impella support prior to high-risk PCI is associated with more complete revascularization in a single setting, reduction in length of stay and time in the ICU, and fewer readmissions. “So I think, trying to minimize hospital resources, actually, paradoxically, …putting this [Impella] in in these high-risk patients prophylactically does seem to be indicated.”
Dr. Moses presents some pains incurred in reopening cath labs and explains that there are still many challenges along the path to fully recovering cath lab volume. He concludes by answering some questions, ending with his social media message for patients: “Don’t neglect yourself. And we’re safe.”