Keywords:
TAVR, COVID-19, Aortic stenosis, triage of patients

Background/Aims:
With the outbreak of the Coronavirus-disease and due to pandemic related shortages of non-COVID-19 medical resources as well as the risk of COVID-19 transmission during hospital encounters, we implemented an allocation algorithm for adjusted TAVR-patient selection.

In order to identify significant differences in TAVR treatment before and after these COVID-19 related adaptions we established a comparison between patients who received TAVR during (in-COVID-19 group) and patients who underwent TAVR procedure before the pandemic (pre-COVID-19 group).

Methods:
The in-COVID-19 group and the pre-COVID-19 group equally consisted of 456 consecutive TAVR-patients. During the pandemic patient-selection, -prioritization and TAVR-treatment-timing followed our allocation algorithm (figure 1) predominantly incorporating ACC/SCAI [1] triage considerations and ESC [2] guidelines.

Preprocedural standard diagnostic work-up, TAVR procedure itself and postprocedural clinical results were observed.

Results:
There was a higher rate of cardiac decompensations/ cardiogenic shocks (pre-COVID-19: 1,3% vs. in-COVID-19: 10,5%, p < 0,00000), conduction abnormalities (left bundle branch block (LBBB) pre-COVID-19: 4,8% vs. in-COVID-19: 10,9%), (severe) symptomatic angina pectoris (Canadian Cardiovascular Society (CCS) classification score II-IV: pre-COVID-19: 11,8% vs. in-COVID-19: 18,7%, p = 0,004), troponin elevation (troponin level above 14 ng/l: pre-COVID-19: 77% vs. in-COVID-19: 84,9%, p = 0,0029) as well as reduced left ventricular ejection fraction (LVEF) (LVEF below 45 percent: pre-COVID-19: 12% vs. in-COVID-19: 18,9 %, p = 0,0056) in the in-COVID-19 group.

The TAVR procedure in the in-COVID-19 group was characterized by a higher rate of pre-dilatation (pre-COVID-19: 35,1% vs. in-COVID-19: 46,3 %, p = 0,0007) and a longer procedural time (pre-COVID-19: 66,9 min (+/-17,5) vs. in-COVID-19: 80,2 min (+/-29,4), p < 0,000001).

During the pandemic there was a shorter length of in-hospital stay (pre-COVID-19: 9,5 days (+/- 9,33) vs. in-COVID-19: 8,4 days (+/-5,9) p = 0,041) and a lower total number of patients receiving TAVR per month (pre-COVID-19: 46,11 (+/- 7,57) vs. in-COVID-19: 39 (+/- 4,55), p = 0,0295).

Conclusion:
The implementation of an allocation algorithm helped to prioritize patients at most critical cardiac condition for TAVR during the pandemic. TAVR procedure showed similar efficacy despite higher complexity in the in-COVID-19 group. TAVR during COVID-19 could be performed with a shorter in-hospital stay and similar in-hospital results.