key: cord-0901996-3jrlgxc2
authors: Workman, Virginia; Freeman, James V.; Obasare, Edinrin R.; Jain, Shashank; Ganeshan, Raj; Burr, Alicia; Blitzer, Mark; Akar, Joseph; Lampert, Rachel
title: Risk of COVID-19 Infection After Cardiac Electrophysiology Procedures
date: 2020-08-28
journal: Heart Rhythm O2
DOI: 10.1016/j.hroo.2020.08.006
sha: 8df7dfaa79a5407631723a00366081cd8a43c26c
doc_id: 901996
cord_uid: 3jrlgxc2

BACKGROUND: During the COVID-19 pandemic, attempts to conserve resources and limit virus spread have resulted in delay of nonemergent procedures across all medical specialties including cardiac electrophysiology. Many patients have delayed care and continue to express concerns about potential nosocomial spread of coronavirus. OBJECTIVE: To quantify risk of development of COVID19 due to in-hospital transmission related to an electrophysiology procedure, in the setting of preventive measures instituted in our laboratory areas. METHODS: We contacted patients by telephone who underwent emergent procedures in the electrophysiology lab during the COVID19 surge at our hospital (3/16/2020 to 5/15/2020, reaching daily census 450 COVID19 patients,) > two weeks after the procedure, to assess for symptoms of and/or testing for COVID-19, and assessed outcomes from medical record review. RESULTS: Of the 124 patients undergoing EP procedures in this period, none had developed documented or suspected coronavirus infection. 7 patients described symptoms of chest pain, dyspnea, or fever; 3 were tested for coronavirus and found to be negative. Of the remaining 4, 2 had a more plausible alternative explanation for the symptoms, and 2 had transient symptoms not meeting published criteria for probable COVID19 infection. CONCLUSION: Despite a high hospital census of COVID-19 patients during the period of hospital stay for an electrophysiology procedure, there were no likely COVID-19 infections occurring in follow up of at least two weeks. With proper use of preventive measures as recommended by published guidelines, the risk of nosocomial spread of COVID-19 to patients in the electrophysiology lab is low.

J o u r n a l P r e -p r o o f Background: During the COVID-19 pandemic, attempts to conserve resources and limit virus 25 spread have resulted in delay of nonemergent procedures across all medical specialties including 26 cardiac electrophysiology. Many patients have delayed care and continue to express concerns 27 about potential nosocomial spread of coronavirus. 28

Objective: To quantify risk of development of COVID19 due to in-hospital transmission related 29

to an electrophysiology procedure, in the setting of preventive measures instituted in our 30 laboratory areas. 31

Methods: We contacted patients by telephone who underwent emergent procedures in the 32 electrophysiology lab during the COVID19 surge at our hospital (3/16/2020 to 5/15/2020, 33 reaching daily census 450 COVID19 patients,) > two weeks after the procedure, to assess for 34 symptoms of and/or testing for COVID-19, and assessed outcomes from medical record review. 35

Results: Of the 124 patients undergoing EP procedures in this period, none had developed 36 documented or suspected coronavirus infection. 7 patients described symptoms of chest pain, 37 dyspnea, or fever; 3 were tested for coronavirus and found to be negative. Of the remaining 4, 2 38 had a more plausible alternative explanation for the symptoms, and 2 had transient symptoms not 39 meeting published criteria for probable COVID19 infection. March 16. The COVID-19 inpatient census at YNHH rose to a peak of 450 cases in mid-April 72 before gradually declining again in early May. During this period, emergent cardiac EP 73 procedures continued, including pacemaker placement for severe bradycardia, generator 74 replacement for those cardiovascular implantable electronic devices (CIED) nearing end of 75 service, cardioversion for severely symptomatic atrial arrhythmias refractory to rate control, 76 ventricular tachycardia ablation for refractory VT, and device extraction for infected CIEDs. A 77 number of measures were instituted to protect patients who did require emergent procedures, 78

including increasing use of masking/ other PPE, and pre-procedure testing, facilitating 79 appropriate cohorting and patient-flow, as well as protocols and education regarding their use. 80 routine healthcare. In many areas, hospitalization rates for COVID-19 are decreasing, and 84 been increasing recognition of morbidity and mortality associated with delays in cardiac care, 86

including arrhythmia procedures such as biventricular ICD implantation for those with advanced 87 heart failure and ablation for those with severe symptoms from atrial fibrillation or atrial flutter. 88

These considerations, along with increased testing and PPE resources, have led policymakers, 89

health system administrators, and physicians in many areas to reopen facilities for nonemergent 90 care. 91 92 However, the COVID-19 exposure risk in this setting remains unquantified, with varying reports 93 of in-hospital transmission among hospitalized patients. 2 . 3 Anecdotally within our community 94 patients have continued to express hesitancy to proceed with elective procedures, and accounts 95 from the lay press suggest similar sentiments nationally. 4 As part of a quality initiative, we 96 performed systematic follow up after discharge to determine rates of COVID-19 infection among 97 patients who underwent EP procedures during the current COVID era. 98 99 Methods 100 who were not reached by telephone; all had documented telehealth visits after the 14-day post-109 procedure interval, including symptom data from the patient history and review of systems. 110

During this time, 157 patients underwent procedures in the EP lab. Patients were excluded if they 111 had tested positive for COVID19 prior to the procedure (N=3) or had been admitted for more 112 than three days prior to the EP procedure, (N=30) to avoid detecting cases less likely primarily 113 associated with the EP procedure, leaving 124 who were included in this analysis. These 114 presented from the outpatient (n=77), emergency (n=11), and inpatient (n=36) Table.  127 128 There were two deaths during the follow-up interval: one 94-year old patient was admitted 129 emergently with complete heart block and heart failure that failed to improve with pacing and 130 of death. The second patient was a long-term care facility resident with death occurring > 60 132 days after an ICD generator change. 133

Of the remaining patients, 7 (6%) described one or more of the symptoms assessed. 3 of these 135 patients had COVID testing after symptom onset which was negative. Of the 4 not tested, one 136 described chest pain diagnosed as ischemia and underwent angioplasty. Another with dyspnea 137 was diagnosed due to pericarditis with increased atrial fibrillation burden. One patient described 138 a 3-day isolated fever with temperature not exceeding 99 o F. The final patient had transient 139 dyspnea for the first three days after atrial fibrillation ablation that self-resolved but was never 140 tested for COVID-19. No patient described illness in a household or family member. In this systematic follow-up of 124 patients who underwent cardiac EP procedures during the 145 peak COVID period in our health system, no patients were diagnosed with COVID-19, nor were 146 any cases suspicious for COVID19 identified, despite a high census of COVID19 at our 147 institution. Four patients described symptoms commonly associated with COVID-19 illness and 148

were not definitively ruled out for infection; however, two of these patients had an alternative 149 explanation for the symptoms and in the other two, symptoms were minimal, brief, and in We did not query less specific symptoms such as headache or myalgia, and cannot exclude the 191 possibility of transmission resulting in mild or no symptoms. It is a limitation of this report, that 192 routine testing was not performed pre-procedure until several weeks into the pandemic, and not 193 performed routinely post-procedure.. This report describe an early experience, during a time 194 period when testing was not easily available and not routinely used even if symptomatic. Similar 195 to the measures taken at our hospital, community precautions also evolved during this time 196 period, with initial limitations on crowd size and closing certain businesses on March 16 th then 197 continuing to evolve. We did not query in detail patients' personal exposures, and so had there 198 been infections, it would have been difficult to confirm their source. However, as we did not see 199 infections, this does not impact the conclusions regarding lack of transmission in the EP lab. 

Guidance for Cardiac 208

Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart 209

Rhythm Society COVID-19 Task Force

College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the 211

Clinical Characteristics of 138 Hospitalized Patients With 214 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

Fear of Covid-19 Leads Other Patients to Decline Critical Treatment. The New 220 York Times2020;A. 221 5