 Welcome to the Texas Heart Institute educational programs featuring cardiology in the time of COVID-19 pandemic. The title of today's presentation is cardiac cath lab and STEMI in the time of COVID-19. So today we have with us Dr. Zvonamir Krazier who's an interventional cardiologist at the Texas Heart Institute and program director of peripheral vascular intervention at THI as well as clinical professor of medicine at the Bayer College of Medicine. And George Eunice who is an interventional cardiologist at THI and associate program director of our fellowship program in addition to being the medical director of PCI and STEMI services at Baylor St. Luke's Medical Center. And my name is Emerson Perrin, I'm the medical director of the Heart Institute and the medical director of the catheterization laboratory at BSLMC. Thank you Dr. Perrin. What are the disruptive effects of COVID-19 pandemic on the healthcare services? We know that COVID-19 is a new pandemic with enormous impact on healthcare, on the hospitals, many specialties, intensive care units, staff and equipment. And cardiac cath lab is certainly not an exception to this particular problem. To improve safety of our patients and staff we have to reorganize our patient flow, we have to reorganize procedural steps and implement new restrictive measures when and how we perform the procedures. If at all possible these measures should be implemented before the worst of the major outbreak of this pandemic is happening in our community. So as we focus this short program in this ever-changing world of COVID we really want to focus on the cardiac catheterization laboratory and some very fundamental and important steps and try to share some of the interactions and results from the interactions we've had with our colleagues around the world and also in the common spirit program. So first of all it seems logical to really want to perform these procedures safely only in a designated COVID-19 environment. And that means a dedicated COVID cath lab in the catheterization laboratory. In the case of THI all the cath labs have positive flow and that is something that as it turns out seems to be an acceptable way to work. Of course keeping in mind the second point is that we really need to be extremely strict in using and implementing PPE for every single procedure. So what are the main things that we've done to prepare the catheterization laboratory in terms of the COVID situation? Well first of all we've gone, this is an ever-moving target and we really have gone from doing some elective procedures and looking at guidelines that have come from Sky and from ACC and letters that have been put out and gradually reducing the volume of the elective procedures too. We've gotten to a point where we really do not do elective procedures now and do what we call tier 2 and tier 1 cases which are emergent or urgent type cases that the patient will impact the patient directly if they're not done. Many times cardiology is an interesting specialty in that it's quite fluid, it's difficult to predict certain outcomes so we do the best that we can with common clinical sense using our judgment many times. There aren't always cookbook answers to these questions. The other things then that we want to do is also be mindful of the staffing of the cath lab. Who are the interventional, are they going to be involved and with the primary idea of reducing the staff that are exposed. And there's three cardinal things that we always want to keep in mind, number one exposure of the patients, number two exposure of the staff and number three preservation of our resources. Dr. Eunice has done a really fantastic job in putting together what I think are some really key questions that I think we can explore, answer and will sort of help us encompass our approach to COVID patients with acute urgent or emergent cardiovascular issues that need to be addressed in the cardiac catheterization laboratory. So the first question is this and I'll let George answer it is do we assume that all patients have COVID-19 until proven otherwise? Thank you Emerson. Thank you Zvonko. That is a very difficult question and certainly a lot of protocols that have been developed have looked at well you have patients that you know are high risk for COVID positivity they may have a fever and cough and those cases are easy but we are knowing more and more that there are patients who can still disseminate the virus who have scant symptoms if any. And so in an emergent situation where you're worried about a STEMI the most prudent thing is probably to assume that the patient is COVID positive, take all the necessary precautions for yourself and for your staff because aside from the human aspects of getting sick if the more people are exposed the more people get put on quarantine and then you don't have enough staff to take care of other patients that may come through in the coming weeks. So I think that's the most prudent thing to do. And I think an important point in that is that testing is critical and availability and the rapidity of testing as it becomes available will have a major impact as we can quickly identify these patients versus now when that kind of delays things and we'll talk about Lord of Balloon time. We sure need that badly. We need rapid tests very, very soon. Second question we don't have a negative pressure cath lab so what do we do with that George? Well as it turns out very few if any centers do have negative pressure cath labs because like all operating suites they're generated they're to be positive pressure environments not to draw in microbes in from the outside but with the COVID patient we don't want to be blowing any aerosolized particles outward but unfortunately turning the positive pressure room into a negative pressure room isn't just a flip of the switch thing. If you're lucky enough to have a window apparently this may be an option. I mean I'm not an engineer but this is what I've heard. The next best thing is to continue in your positive pressure environment as we mentioned before but maybe with the installation of a HEPA filter or other relevant filters to sort of do the best you can to filter out any microbes from being transmitted. Yes we were recently on a webinar with international and national centers and actually it was interesting to see when our colleagues in Chicago had they had transformed one of their rooms to have a HEPA filter in it. I thought that was very interesting. Okay let's go to the next question so should cath lab staff wear full PPE for all cases? I think that is certainly the most prudent thing to do in the spirit of protecting everybody as much as possible. It does probably add time and some burden to the case for every technician or scrub tech or every nurse to be in full PPE because that's not what we normally do but I think that is the most prudent course. Okay and now let's get into a little bit more when we're talking about these urgent and emerging cases we're really going to start talking a little bit about STEMI specifically because that's what we're dealing with. And just as an aside I think it was interesting that many centers around the world and in the country have noticed the actual decrease in STEMI volume and that's maybe something that changes or that's temporary or we really don't know the explanation for maybe some of these patients are staying at home and we'll be seeing them later. Nonetheless we haven't gotten the idea that the cath labs are being inundated with these acute cases although there's some peculiarities that we need to talk about. So first of all should stable or low risk patients be considered for thrombolysis and if so where do you do the thrombolysis and then how do you follow up on that? Yeah very complex question but I think most centers are definitely considering use of thrombolysis even in PCI capable centers in particular patients who may be low risk. The use of thrombolytics up front if successful may obviate their need to go to the cath lab at any point and especially you know if you have a patient who is highly suspicious for COVID if you can keep that patient out of the cath lab that that may be a great thing to do if there's not much of a trade-off in terms of patient outcomes. So you know what is a low risk semi-patient? The recent sky guidance sort of outlines several features that may be relevant for that but patients who are maybe a hemodynamically stable inferior MI, lateral MI but anybody who's you know has hemodynamic instability would not really fit in that category. So I think thrombolytics devices should actually to absolutely be considered because you know you may protect your staff and you may conserve now as to where it occurs that's that's a bit more complicated because if you're assuming these patients have come in through the ED then probably it makes most sense for the patient to get thrombolytics in the ED. Most EDs have have some comfort with this concept from taking care of stroke patients and so hopefully you know modifying existing protocols to allow thrombolysis to occur for STEMI patients would be sort of a lateral move in that regard. There may be some centers however where they don't feel comfortable doing that and what the patient may move to an ICU but these things are probably institutionally based and need to be carefully thought out as part of your protocol and then the question becomes well what happens if the thrombolysis is successful and the patient's doing fine then you know you have some time to decide if you're going to take the patient to the lab and during that time you can learn whether or not the patient is COVID positive. As it stands now you're lucky if your center can get you results in a day and so if the patient has successful thrombolysis you monitor them in the COVID unit you wait for the COVID results to come back and then you know what's going on with the patient and you can decide do we need to risk stratify this patient further and take before taking them to the lab or do we just take them to the lab or do we can or what do we do next. Now if they're COVID positive it becomes more complicated because there's a you know you may say gosh the sooner we can get this patient out of the hospital the the less risk there is everybody else and follow up the coronary disease at a later time frame. These are complex questions that are going to of course be very individualized but they're very important. And I don't want to give our listeners also the idea and I don't think that you've done this but just to kind of reinforce the point is that what was your impression in that how are most of the centers around the world and here in the U.S. dealing with STEMIs did you get the feeling that there's just this shift of thrombolysis or is there really continued mainly direct PCI going on? Yeah well my impression even coming from the gentleman that we heard coming to Italy was that primary PCI was still the mainstay but I think a lot of people are looking at it as well as we lose if the availability of PPE continues to go down and even the availability of healthy doctors and staff goes down we may need to really look at thrombolysis and more patients but I think currently outside of some papers that came from China everybody else still seems to be favoring in practical time practical work using primary PCI most of the time. Okay and and then that takes us to an interesting question which relates to getting a clue you know some of these patients with COVID they have myopericardial involvement and they may have really mycarditis with ST changes that look like a STEMI and then what can you do to identify these patients so should ECHO be used more often prior to deciding to go to the cath lab and then how do you make that logistically happen how do you operationalize that? Right so I think this is a really important and useful point and even even before that you know the history is even more important than ever you know all SC elevations are not STEMI's you may have EKG changes in a patient who you know has a febrile illness and that's a very different situation than an EKG change in someone with a Q onset of chest pain but you know when you have a situation where you're not certain what's going on but you do have ST changes a real great way to help to understand that it's a do a quick ECHO and you know if you have a ECHO that shows wall motion abnormalities in the same distribution where you would expect them to be based on the EKG then that supports that this may actually be a true STEMI whereas if you see a perfectly normal appearing LV or you see sort of global wall motion you know global mild hypokinesis in someone with like a inferior ST changes where it doesn't really add up then that might tamper your enthusiasm to pursue it as a STEMI and take the patient to the cath lab or certainly to give some politics so I think ECHO can be a really useful adjunct and as to who would perform the ECHO this is going to be very institutionally dependent academic centers like ours are fortunate to have capable fellows who carry around a portable echo machine and can come look at the patient ultrasound by ultrasound real quick and tell us what's going on other centers may have to have protocols involving either in-house staff or emergency room doctors who have sufficient training to be able to really draw those conclusions okay and so I'm going to skip to question number seven before I go to number six because it's kind of related let's talk about cta a little bit how how does that fit in can it help what are your thoughts on that well I think it's a it's a it's a very interesting idea in patients cases where you don't really know what's going on if you don't think if you're not sure if it's a STEMI or not even after you maybe done a quick look at go theoretically doing a cta might be very beneficial to at least you know get a sense of certainly the proximal coronaries let's say the heart rate you know as of course has to be low enough to get a really good study but you know in most patients you can at least see the very proximal coronaries and see what's going on but the problem with doing a cta is of course then you expose the CAT scan staff and the CAT scanner itself to potential you know exposure to the virus and that needs to have a big clean afterwards and another is availability I don't think most centers can do cta is a good coronary cta 24-7 in most centers and certainly at least in our center the best trained staff for doing that are only available during daytime hours so it becomes a little more complicated I think it's something that's probably evolving and may have its place but it's a little bit hard to implement so it really looks like echoes sort of the practical quick way to see if a STEMI is really a STEMI if you're in doubt about that I think it's helpful yeah so now let's shift gears a little bit and think about let's say we're taking a patient we decided he has a STEMI we're taking him to the cath lab what about intubating that patient what's our threshold for doing that and and what's the consensus on that so there's there's been a lot of discussion about perhaps having a lower threshold to intubate these patients prior to taking to the cath lab I know in our center intubations of suspected COVID patients or emergent patients are only being done by anesthesia these days as opposed to by ER staff or pulmonary or other people in order to make sure that it's done in such a fashion as to minimize risk of aerosolized particles and if you have a patient with a STEMI there's this is a patient who certainly at risk of decompensating in the next you know 10 minutes 30 minutes an hour and during the procedure and if that patient crashes in the cath lab you risk exposing the entire cath lab staff to aerosolized particles whereas if you are more proactive and intubate people on the front end prior to bringing them up there you can you know now the respiratory circuit is closed already and you're not going to have aerosolization of particles and incidentally if you have done a coronary cta before taking this patient to the cath lab you'll also see the lung windows and you might have a clue as to what's going on if you start to see ground glass of plasticities on those patients which are frequently look much worse on CAT scan than they do on x-ray or even clinically you might also have a lower threshold to intubate that patient prior to leaving the cath lab for the safety of yourself yourself and your staff okay so where do we want to preferentially intubate these patients do we do it in the emergency room do we do it in the icu well i think i think in the i think these patients who are STEMIs they're in the ER and they before they go to the cath lab i would do it in the ER in most cases okay so bringing up door to balloon time and i and you know uh this whole COVID crisis puts a little bit in perspective uh you know we're always so worried about ncdr metrics and this and that well right now we're worrying about you know saving people's lives and and and it doesn't really matter the door to balloon time in terms of the metrics but it does matter in terms of patient outcomes right and if it takes an hour to let a room clean up and and the particle settle down and then you have to do a terminal current clean depending on your volume and how things go they're going to be delays in the system and so what is this all going to do to our door door to balloon time and it's sort of in that perspective um and and how do we think about thrombolysis again so i'm just kind of bringing up that point because it's important yeah you know i i agree with your sentiments you know we spent so much time thinking and talking about metrics and normal times and now it just seems so so relatively silly to be talking about these other esoteric numbers when we're trying to just deliver care at this point um but it's of course it's a relevant point um not only with the cleaning but these ancillary tests we're talking about um like a CAT scan or an echo or just getting the the PPE for the whole staff that takes additional time you know these are our delays we're not accustomed to and so you know if you can't get your door to balloon time in the acceptable manners anymore then you know if we're starting to treat patients two hours after they present well maybe we would have been better off giving them thrombolysis if it was a stable patient because they would have received a chance of reperfusion right away and so that's a very difficult question to tease out and i think it's going to be answered as by each institution as they go forward you can carry these patients and see how much delay they are seeing prior to getting these patients into the cath lab and if there appears to be a lot of delay then you know again the the idea of giving thrombolytics in certain cases might be considered better just because there's a chance of reperfusion faster yeah i think there's a lot of things that we don't know um our answer to some of these things may change over the next even even in a week and and and as we get a more practical sense of these things maybe we'll even go in a different direction so um the final question i want to ask you is shifting gears from stemmy to end stemmy so what is the general feeling uh regarding treatment of end stemmy well um in the spirit of everything that's going on and protecting staff and concerning pve i think the general mood on this is to be more conservative you know i think we have generally had a pretty aggressive um strategy towards these non stemmy patients but the truth is many of them can be treated medically um for their end stemmy and then only undergo catheterization if they have certain high-risk features um and so i think certainly a slow approach is best in these patients um right now and of course if there's any instability that's an easy one but if they're if they're very stable uh there may not be any good reason to take that patient to the cath lab right now you could send them home see how things go and then reconsider and and i agree and that's a message that i heard very clearly from our colleagues or from around the world and here in the us is really the the shift uh and i think this varies regionally as well but you know uh the shift in uh how we we manage these patients and really really only thinking about an invasive strategy in people with with ongoing ischemia who who might be in trouble may i ask you a couple of questions that are also very important and related to this topic and uh both of you can answer them because i think they're important one is should we uh dedicate covid specific cath lab for those covid positive patients and uh we at our institution have over 100 international cardiologists should be allowed all of them to perform procedures to be exposed to a potential covid the 19 infection or should we uh decide that that we'll have a dedicated team that will be doing those procedures to avoid excessive use of pps and also exposure to a many of our internationalists so maybe each of you can address this question well i'll i'll just start with the the personnel issue again that the practice patterns really vary around the country you know at texas heart we still have private practice groups and and one of the interesting things that i've seen is some of the groups dividing their their you know groups that have you know let's say six doctors dividing them into the interventionists into teams where some of them are off or not in the hospital for for a period of time and they really alternate when they come in but i think it's really gonna vary a lot with the the the practice patterns locally at different places so the reason that was asking this question because in other countries where they're social is medicine they're basically uh limiting the number of interventionists that are doing the procedure that is true in a lot of european countries and if we uh get a severe severe increase in number of the cases we might have to consider something of that kind also here in the united states george any other comments relate to this i think that's that's um as emerson said that i think it's uh something that's going to be really institution dependent i've heard um of different proposals that are in different countries i mean different institutions here in the u.s and some are doing just what emerson was talking about amongst themselves is the staggering staffing of the cap up from a position standpoint there was also a discussion on our call last night about whether physicians over 60 should be excused from doing cases for the time being and of course it's going to depend on well how many people this is does that leave you does that leave you the only one guy or you know do you have a bunch of young guys so there's a lot of things to think about um in in this regard and trying to keep everybody safe well thank you very much if you don't have any other questions i would like to thank to you emerson and to george for your very valuable contribution to this texas art institute program on the cardiac cath lab and stemming in the era of covid 19 thank you very much for your participation it's a pleasure to work with you on our educational programs for those of you that have tuned in to this program please join us for our next program on cardiology in the time of covid 19 stay healthy and treat your patients prudent thank you very much