Heart failure can be caused by various conditions, including valvular heart disease or Structural Heart Disease (SHD), which is a problem with the tissues or valves of the heart. In fact, SHD is one illness that can place a heavy burden on both healthcare and social care systems and wider society.
An ILC report titled ‘The invisible epidemic: Rethinking the detection and treatment of structural heart disease in Europe’ defines SHD as an age-related cardiovascular disease (CVD), which has a high mortality rate if not detected and treated early enough. It also decreases the quality of life for those living with the condition, with severe SHD causing fatigue and shortness of breath even at rest. Moreover, the report estimates that the number of people living with SHD will go up to 20 million by 2040 – a 43 per cent increase.
Heart conditions that fall in the SHD category include aortic valve stenosis, atrial septal defect (ASD), heart valve disease, mitral valve regurgitation, left ventricular hypertrophy, cardiomyopathy, and myocarditis.
According to the Burden of valvular heart diseases: a population-based study, the prevalence of such valvular diseases was reported to have increased with age, from 0.7 per cent in 18-44-year-olds to 13.3 per cent in the 75 years and older group.
In the last 10 years, considerable progress has been made in transcatheter treatments. SHD procedures have improved and developed, allowing more patients to get minimally invasive heart valve operations, which have extended life and improved quality of life for many patients who were previously considered illegible for surgery. Additionally, clinical trials continue to help define the precise role these treatments will play as technology advances. However, integration of training methods for physicians to successfully carry out procedures is required, especially in the current landscape of the pandemic.
Impact of COVID-19 on SHD patients
SHD patients are at higher risk of contracting COVID-19, with serious implications deteriorating their immunity. Especially for patients with mitral and aortic valve disease, the repercussions of SARS-Cov-2 can lead to death.
According to the Journal of the American College of Cardiology, myopericarditis, malignant arrhythmias, and biventricular heart failure are some of the cardiac complications associated with COVID-19. In addition, the case fatality rate was substantially more significant in those who had pre-existing CVD, 10.5 per cent vs 2.3 per cent, in the largest case series to date of over 44,000 COVID-19 patients from China.
Acute myocardial damage is common in patients with severe implications of COVID-19, as shown by higher troponin levels, which are closely linked to clinical degeneration and increased mortality. Patients with a history of CVD have an adverse prognosis when they have a myocardial infarction. Studies have repeatedly shown that older people have considerably higher case fatality rates (8–12), which might be due to an increased frequency of comorbid illnesses and age-related reductions in T- and B-cell activity.
The burgeoning demands of facilitating treatment for COVID-19 patients has hindered triaging care for cardiac patients, including elective procedures, being either put on hold or cancelled. Patient management during these intervals is crucial, in addition to accessibility to the hospital and doctors. Through administering appropriate medication, patient monitoring and analysing cases based on severity during the waiting period can be lifesaving.
As emergency wards reached their highest capacity, cardiac surgery procedures which are categorised as emergency cases, were in a challenging position. Admitting elective cardiovascular cases meant putting patients at risk of contracting COVID-19. During the pandemic globally, healthcare specialists faced the dilemma of deciding between patients based on acuteness and stage of complication.
“This difficult balancing act placed a significant strain on cardiac specialists, and unfortunately, increased mortality due to the lack of hospital beds and availability. However, as we adapt and many hospitals around the world facilitate means of providing patient care to all, we are nearing towards the new normal, especially in the UAE,” said Dr Rafik Abu Samra, Cardiologist at Glucare Integrated Diabetes Center.
One of the most crucial steps to safeguard patients with aortic stenosis and multiple comorbidities should be ensuring they are vaccinated before the procedure. Secondly, time management plays an essential part. From the time the patient walks in for the procedure until discharge, hospital stay should be minimised, or patients should be isolated in both elective or urgent cases to avoid exposure to infection.
Administering TAVI during the pandemic
Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is an innovative technology. Next-generation devices and careful patient selection will help to reduce TAVI’s limitations, such as a paravalvular leak, conductance abnormalities, ischemic stroke, and vascular comorbidities. A journal published in the Spanish Society of Cardiology states that TAVI has transformed AS patient treatment and has been implanted in over 250,000 people in over 65 countries worldwide. In 2015, approximately 70,000 patients were implanted, with that number expected to quadruple to over 280,000 by 2025.
However, the pandemic has changed the dynamics of triaging TAVI patients. Due to several reasons, TAVI is considered an elective case, which during the pandemic came to a halt, as treatment of COVID-19 patients was prioritised. Unfortunately, patients in need of TAVI are at a higher risk of contracting COVID-19 and high mortality rate due to the aortic stenosis itself. With a 25 per cent yearly mortality rate, it’s a serious cause for concern for patients waiting for the procedure.
A recent randomised PARTNER 3 Trial, which provides clinical evidence, compared outcomes between transcatheter aortic valve replacement (TAVR) and open-heart surgery. Reportedly, the trial showed a remarkably low death and disabling stroke rate of 1.0 per cent at one year versus 2.9 per cent for surgery. Based upon these clinical findings at one year, TAVR can be considered as the preferred therapy in low surgical risk aortic stenosis patients.
TAVI is a class I indication in the American Heart Association/American College of Cardiology and European guidelines for symptomatic patients with severe AS who are not surgical candidates. A recent paper, Transcatheter Aortic Valve Implantation During the COVID-19 Pandemic, illustrated the efficacy of TAVI and found that TAVI procedures can be performed effectively and safely during the COVID-9 pandemic, using a minimalist approach, early discharge, and by maintaining proper use of personal protective equipment.
“TAVI as a minimally invasive procedure has many benefits for the patients seeking successful treatment, which gives them a new lease on life. It does not require an open-heart procedure. Initially, TAVI was synonymous with elderly patients or those suffering from cardiac failure and comorbidities, which disqualified them from traditional surgery and aortic valve replacement. Structural heart disease patients are the perfect candidates for TAVI. The procedure is innovative, quick with positive long term patient outcomes and reduced discharged periods. TAVI patients are discharged on the same or the next day. Recovery depends on individual circumstances, but most people can resume work in two weeks and can feel fully recovered within six to 10 weeks. Due to these factors, soon TAVI candidates will include younger patients as well,” concluded Dr Rafik.
Article sponsored by Edwards Lifesciences