ABC | Volume 115, Nº1, July 2020

Review Article Costa et al. Cardiovascular Imaging and Interventional Procedures Arq Bras Cardiol. 2020; 115(1):111-126 5.2. Indication for a Procedure Thorough assessment of the clinical urgency of an interventional procedure during the pandemic is essential. Ideally, that should be a joint decision of the physician performing the procedure, the clinical cardiologist, and the patient. 5.3. Stable Coronary Artery Disease Risk profile assessment should be individualized, considering clinical findings, complementary tests and symptoms. Usually, elective procedures for stable CAD should be postponed until after the pandemic. Patients with stable CAD, as those assessed in the ISCHEMIA study, have a favorable outcome with optimized clinical treatment. It is worth noting that the ISCHEMIA trial has not included patients with the following characteristics: estimated glomerular filtration rate lower than 30mL/min/1.73m 2 of body surface area; recent acute coronary syndrome; unprotected left main coronary artery stenosis of at least 50%; left ventricular ejection fraction lower than 35%; NYHA functional class III/IV heart failure; and unacceptable angina despite the use of optimized medical therapy. 46 The ISCHEMIA trial has shown a higher incidence of acute myocardial infarction in patients with stable CAD under conservative treatment as compared to those submitted to revascularization. That, however, has occurred only after a six-month follow-up, corroborating the deferral of interventional procedures in that subgroup of patients. 46 5.4. Non-ST-elevation Acute Coronary Syndrome (NSTE-ACS) It is worth noting that 7-22% of the patients with COVID-19 have myocardial injury with significant elevation in myocardial necrosis markers, which might correspond to type 2 acute myocardial infarction or myocarditis. 7,10 Type 2 acute myocardial infarction should be distinguished from “primary” acute coronary syndrome, and deferral of invasive stratification considered in the former, mainly if the patient is hemodynamically stable. For most patients with NSTE-ACS and suspected COVID-19, diagnostic tests for COVID-19 might be performed before cardiac catheterization, allowing to a more sensible decision-making about infection control. Unstable patients with NSTE-ACS, whose instability is due to acute coronary syndrome, should follow the urgent care flow. Figure 4 shows a flowchart for the care of confirmed cases of NSTE-ACS according to the diagnosis of COVID-19. Readiness to discharge after revascularization might be important to maximize the availability of hospital beds and reduce the patient’s exposure inside the hospital. Follow-up via telemedicine can be an additional tool in a time when restriction to people circulation is recommended. 47 5.5. ST-elevation Acute Myocardial Infarction (STEMI) STEMI has high morbidity and mortality, and primary percutaneous coronary intervention (PPCI) should be deemed the therapy of choice. 48 However, in face of the current burden imposed to health systems by COVID-19, some centers have recommended fibrinolysis as the first-line treatment of STEMI. 49 This is a controversial issue that should take into account the COVID-19 diagnosis probability, the patient’s clinical severity, the availability of resources, and the estimated time to perform PPCI. At the time this article was written, PPCI was recommended as the treatment of choice for STEMI in patients with COVID-19. If resources become scarce, the clinical severity hinders patient’s transportation to the CCL, and the door- balloon time is inadequate, the cardiology staff might decide to use thrombolytics, rather than PPCI, for patients with COVID-19 and STEMI. In hospitals with no access to a CCL, fibrinolysis remains the standard treatment. 50 Figure 5 presents an algorithm with the care for STEMI in the current pandemic scenario. Because of the need for emergency care, all patients with STEMI should be considered initially as having COVID-19, and the cardiovascular findings should be prioritized until the infection can be properly investigated. It is worth noting that patients with COVID-19 can have diffuse or regional ST-segment elevations, with no obstructive lesion justifying the alteration. 51 Those with obstructive CAD have higher levels of troponin and D-dimer. 51 Thus, caution is recommended in interpreting the electrocardiogram, mainly in patients with severe pulmonary findings, whose transportation conditions are not safe. In that scenario, echocardiography can be considered, as long as it does not delay CCTA, when indicated. 51 5.6. Procedures for Structural Heart DiseaseManagement During the COVID-19 Pandemic a) Transaortic valve implantation (TAVI): Aortic stenosis (AS) is a progressive disease that affects patients with advanced age vulnerable to death from infection. The importance and clinical urgency of TAVI require a joint decision-making by a multidisciplinary team (clinical and interventional cardiologists and surgeon). That decision should weigh the risk of patients’ exposure to COVID-19 contamination against their risk of an acute, potentially fatal event. 52 Patients with indication for TAVI should be closely followed up by telemedicine during this pandemic. Asymptomatic patients with significant AS can be followed up on an outpatient basis. Those with complicating echocardiographic findings (Vmax > 5.0 m/s, valvular area < 0.7 cm 2 , mean left ventricle/aorta gradient > 60 mmHg), syncope, reduced left ventricular ejection fraction due to AS and NYHA functional class III/ IV, who are at higher risk for events, 53 ideally should not have their TAVI postponed. Compared to open-chest surgery for aortic valve replacement, TAVI can reduce the need for intensive and anesthesia care during a pandemic. If TAVI is to be performed, preprocedural screening with PCR for COVID-19 might reduce the risk for the healthcare personnel. b) Mitral valve clip: mitral valve clip procedure can be considered for unstable patients if resources allow and should be postponed for lower-risk patients. c) Closures of patent foramen ovale and atrial septal defect: should be postponed. 118