Valve Disease Plus COVID-19 Often a Lethal Combination, Registry Shows

Four in 10 patients who contract COVID-19 on top of valvular heart disease (VHD) die within 30 days of hospital admission, according to multicenter registry data. That mortality rate, researchers say, is perhaps enough to justify pursuing valve repair or replacement even in the context of SARS-CoV-2.

More strongly, it’s a reminder that patients with valve stenosis or regurgitation should obtain timely treatment in the hopes that, were they to develop the viral disease, their outcomes might be less dire, Danny Dvir, MD (Shaare Zedek Medical Centre, Jerusalem, Israel, and University of Washington, Seattle), told TCTMD.

“We talk all the time about how to reduce the burden of [COVID-19] mortality, what we should do in order to improve outcomes for our patients while we wait for a vaccine,” said Dvir. “We have a solution for valve disease—before they get infected with COVID, we can treat these valves.”

As has been seen in other areas of cardiovascular medicine, famously the so-called missing STEMIs, Dvir said people with existing VHD have been reluctant to seek care due to fears of getting sick. For these people, the delay in care alone puts them at risk. There’s also the possibility they will develop COVID-19 during this time, he noted.

What’s clear from their data, Dvir urged, is that VHD should be treated conventionally during the pandemic. The study isn’t randomized, he acknowledged. “But the clinical outcomes of those having TAVR while infected with [SAVS-CoV-2] are quite good, to be honest. These patients did well.”

The Details

Dvir, presenting the registry results today in a COVID-19-dedicated session during the virtual TCT Connect 2020, pointed out that there are no published data on this topic. Their international registry tracked 136 people with COVID-19 and severe VHD: 74 with aortic stenosis (AS), 28 with mitral regurgitation (MR), 14 with tricuspid regurgitation, 11 with aortic regurgitation, and nine with mitral stenosis.

Average age was 80 years across the cohort, though lower (mean 70.6 years) in patients with aortic regurgitation. Slightly more than half of patients were men, with high prevalence of hypertension (77.2%), diabetes mellitus (34.6%), CAD (38.2%), and history of dyspnea (overall 83.1%, though the rate was only 55.6% in the mitral-stenosis group). One-third of patients (32.5%) each were in NYHA class II and III prior to COVID-19, with 5.1% in class IV.

COVID-19 management consisted of antibiotics (84.3%), hydroxychloroquine (74.6%), antivirals (53.7%), corticosteroids (32.8%), inotropic support (8.1%), interleukin-6 inhibitors (2.2%), and convalescent plasma infusion (0.7%). One-quarter required noninvasive mechanical ventilation and 11.8% invasive. Most patients (44.9%) received no anticoagulation, which Dvir said was surprising, while 22.8% were given low-molecular-weight heparin, 14.7% warfarin, 9.6% non-vitamin K antagonist oral anticoagulants, and 8.1% heparin.

For VHD, treatment strategies varied by disease state. The vast majority (84.6%) were managed conservatively. Interventions, among those who received them, occurred at a median of 5 days after admission. In the aortic-stenosis group, 17.6% of patients underwent valve replacement (84.6% TAVR). In the aortic-regurgitation group, 18.2% had replacement (one TAVR, one SAVR). Valve repair was performed in 7.1% of the MR patients. Balloon valvuloplasty was done in 2.7% of people with AS and 22.2% of those with mitral stenosis.

Aortic valve replacements were numerically the most common among all the interventions—though still done in only 13 people. Here, mortality rates were 11.1% for patients younger than 80 and 16.7% for those who exceeded that cutoff. Untreated severe AS, however, was linked to much higher mortality: 23.5% in younger and 59.5% in older patients (P = 0.005 vs AVR).

By 30 days after hospital admission, mortality was 41.8% overall. It trended higher in the severe MR group (54.4%) compared with the severe AS group (42.6%) and other severe VHD groups (29.7%; P = 0.09).

“Valve repair or replacement in appropriate patients should be considered in those at risk for infection, and possibly during the infection,” Dvir concluded during his presentation. “Although the present study suggests this approach may be lifesaving, further studies are warranted to confirm these results.”

But Is it Safe?

Speaking to TCTMD, Dvir reassured that these procedures can be safe: “We fear that the infection can involve the precious newly implanted valves that we’ve just put in. The thing to remember is that [the virus] does not infect the valve. . . . The valve will not damage the heart.”

He also said that for operators and healthcare teams, it was feasible to do these cases without endangering themselves. COVID-19 patients are undergoing other sorts of heart-related procedures, like primary PCI, Dvir pointed out. “It’s not something that we don’t do. The challenge is how to select the patients that should have a procedure once they have severe valve disease and get infected.” For example, frailty may be a barrier.

A hallmark of COVID-19 has been the disease’s prothrombotic state. Asked about this in relation to either VHD itself or the outcomes after intervention, Dvir told TCTMD he has encountered thrombotic complications. Usually, however, these occurred in previously implanted artificial valves; he has heard of no instances of valve thrombosis in COVID-19 patients who underwent TAVR.

Following Dvir’s presentation, session moderator Sahil A. Parikh, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), said “it’s quite sobering to see what the data look like in these patients with severe valvular heart disease and concomitant COVID-19 infection.”

Parikh asked for more details on what precautions were used beyond normal personal protective equipment. “For example, in the US we’re increasingly using transesophageal echo to guide [cases] without intubation and using a conscious-sedation approach. But there is concern about viral spread during any of these kinds of aerosolizing procedure,” he said, adding, “How did you do the procedures actually to minimize risk to your staff?”

Dvir said he personally performed a few of these TAVRs. His main focus was doing the cases quickly but cautiously, with the main discomfort being that the operating room was quite hot while wearing personal protective equipment.

Timothy D. Henry, MD (The Christ Hospital, Cincinnati, OH), also a session moderator, said he didn’t know of similar registry data being widely collected in the United States. What this international registry shows, though, is consistent with reports from other areas of medicine—whatever the best clinical care is normally, “we should do it, with or without the COVID,” he commented. “I think that’s a really important take-home point.”

Patients, however, may not be comfortable with having an intervention, Henry cautioned. “We personally here had six patients—even though we tried to convince them to get their procedure [they] were scared of coming into the hospital.” This was especially true for elderly individuals wary of being alone in the hospital when COVID-19 prohibited their family members from joining them.

Here, he asked, “what were the reasons for not doing a procedure?”

Dvir attributed the variation to the large number of centers participating in the registry, each with its own culture and practices. “In some centers, they said: ‘No way, we’re not going to treat severe aortic stenosis patients with TAVR because we’re overwhelmed. We will not do it,’” he reported.

He countered, though, that there could be benefits to public health. “I am saying to my patients, ‘Don’t wait at home. Do not wait. If you get infected when you have severe aortic stenosis, the clinical outcomes are very poor,’” Dvir added.

Renu Virmani, MD (CVPath Institute, Gaithersburg, MD), a panelist, agreed. “I think patients need to be educated that if you’ve got valve disease you’re better off treating it before you get COVID. Obviously prevent getting COVID—that’s the best thing you can do. But you can’t always control it.”

Also speaking during the panel discussion, Mamas Mamas, BMBCh, DPhil (Keele University, Stoke-on-Trent, England), predicted that a “public health crisis” is on the way in relation to VHD in the United Kingdom, where he and other investigators looked into practice patterns. Over a 4-month period, there were an estimated 2,294 patients with severe aortic stenosis who did not undergo valve replacement. “We know these patients are on the waiting list. . . . We’ve got to work out how we’re going to treat them,” he said, noting that hundreds may die before it’s possible to do so.