Symptomatology and appreciating classic signs associated with some of the VHDs may become challenging given that some patients are attached to multiple therapeutic machines like ventilators. Dyspnea and chest pain, especially in the setting of COVID-19 infection, may pose an extremely challenging clinical conundrum of whether the symptoms originate from COVID-19 per se or represent VHD manifesting in the setting of metabolic derangement from the infection.
The utility of inflammatory markers such as D-dimer, interleukin (IL)-6, ferritin, and lactate dehydrogenase (LDH) may aid in pointing to a rather severe case of COVID rather than VHD, even if severe VHD by itself does not lead to elevated levels of inflammatory markers. Given the nonspecific nature of these markers, they may not be completely applicable in a host of different clinical scenarios (e.g., bacterial sepsis complicating presentation). Chest X-ray, while an important initial and conveniently available tool, is not very specific when it comes to diagnosing valvular disorders. Straightening of the left border of the heart or the so called “double-density” signs associated with MS, albeit rare, may aid in diagnosing specific valvular disorders. The presence of prosthetic valves, when history is not very clear, may also be appreciated on chest X-ray.
Echocardiography continues to remain an indispensable tool in the evaluation of patients with COVID-19 suspected to have VHD. Not only is it an invaluable resource in diagnosis of these conditions, but it also helps in elucidating the hemodynamic consequences occurring in these patients, given the widespread systemic manifestation resulting from COVID-19 infection. A bedside point-of-care ultrasound (POCUS) is the most commonly used initial strategy to gather preliminary information given the rapidity with which it can be performed. This should be followed by a formal TTE with a dedicated scanning protocol to obtain more detailed information. Echocardiography remains the most important diagnostic test in understanding valve structure and function in suspected cases as it is cheap, easy to perform, and readily available. Although it can be difficult to obtain images of satisfactory quality in certain patients (e.g., obese, mechanically ventilated, those with chronic obstructive pulmonary disease [COPD]), using Doppler to obtain gradients across valves can still provide sufficient clinical information for the management of critically ill patients.
Invasive testing finds limited utility as it risks significant exposure and contamination. Although TEE can be used to provide more detailed information about valvular pathologies, the application of such a modality in patients with active COVID-19 infection carries a significant risk of exposure to healthcare professionals due to potential aerosolization. It should only be pursued after understanding the risk-benefit assessment and if performing the test would meaningfully add to a patient’s care.
At the moment there are no evidence-based guidelines available on the management of VHD in patients with confirmed COVID-19 infection. Based on the European Society of Cardiology’s (ESC) guidance on the management of cardiovascular diseases during the COVID-19 pandemic, we recommend a risk-stratified approach in managing patients with VHD. At the peak of the pandemic, given the divergence of all the resources and personnel available to care for patients battling COVID-19, low-risk patients with stable disease can be safely managed at home with aggressive monitoring of symptoms and telehealth-directed visits. High-risk patients, especially those who present in a state of decompensated disease process, may need emergent or urgent treatment for a specific valvular disorder.
A heart team approach involving holistic assessment of patients, including their symptoms, laboratory makers, and imaging findings, should be undertaken by a dedicated team of cardiologists, interventional cardiologists, and cardiothoracic surgeons to stratify patient risk. This helps in determining the necessity and degree of interventions and if they are required at all.
Patients with mild to moderate and severe VHD, but with minimal symptoms, should be managed with frequent telehealth visits focused on symptom assessment. Severe symptoms, on the other hand, merit a time-sensitive approach. Although medical therapy in patients with VHD and COVID-19 remains the cornerstone therapy, surgical interventions may be considered under special circumstances. For example, in a patient with AS syncope, New York Health Association (NYHA) Class III/IV symptoms, or angina, higher mean gradients (>50 mmHg) and peak velocities (>5 m/sec) on TTE would warrant urgent need for intervention. Similarly, in patients with decompensated disease with significant hemodynamic compromise precipitated from COVID, a trial of specific minimally invasive interventions could be considered within the framework of a heart team discussion. Physicians, however, should have a careful discussion about the risk and benefits of procedures with patients and family. Being frequently associated with systemic thrombosis, patients with COVID-19 infection considered for invasive procedures like transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) should be carefully monitored for the development of such complications. The futility of interventions and procedures among patients expected to have poor prognoses warrants important consideration and rationale, and this should be explained to these patients’ families.
As discussed above, the mainstay treatment for all VHDs tends to revolve around medical therapy, such as blood pressure and heart rate control and decongestion via diuresis. An important aspect of this also should focus on treatment of the primary offending condition, namely the various systemic manifestations of COVID-19. This section focuses on the various therapeutic interventions catered to each valvular disorder.
Decompensated AS patients, especially when medical management fails to show improvements, should be considered for emergent interventions. Balloon valvuloplasty (BAV) or TAVR/transcatheter aortic valve implantation (TAVI) can be a last resort. SAVR is frequently not a conducive option in such patients given their high risk, as assessed from various risk score calculators like the Society of Thoracic Surgeons (STS) score or EuroSCORE. BAV may be considered in selected acutely decompensated patients with favorable anatomy as a bridge to a more definitive intervention (TAVR/SAVR) at a later stage when they are hemodynamically more stable.
Selection of vasopressor agents in patients with cardiogenic and septic shock merits consideration of pathophysiology associated with AR. Dobutamine with its inotropic and chronotropic response and relative absence of vasoconstriction may be a suitable choice since tachycardia offers a favorable profile by shortening diastole and reducing time for regurgitation. TAVR can be a possibility if the aortic and valvular anatomy permits. However, like all other valvular pathologies considered for intervention, risk-benefit assessment along with feasibility and futility should be given due importance. (1-6)
Patients with stable primary and secondary MR with minimal or no symptoms can be managed with careful monitoring with optimal medical management, like goal-directed medical therapy for ischemic and nonischemic cardiomyopathies provided there are no contraindications like usage of afterload-reducing agents with septic shock. Patients who present with decompensated symptoms in the setting of acute primary MR (e.g., chordae rupture) and secondary MR not responding to medical management should be considered for transcatheter mitral edge-to-edge repair. However these procedures are frequently carried out under the guidance of TEE, which predisposes operators and TEE operators to significant exposure.
Medical therapy remains our initial approach for decompensated heart failure symptoms. Diuretic therapy along with rate control, especially with AF, remains the mainstay. A beta blocker, with an added advantage of reducing cardiac output in addition to curbing tachycardia, which frequently occurs in the setting of infection with SARS-CoV-2, can be a useful agent. Patients with COVID-19 and MS who develop AF should be anticoagulated with heparin, vitamin K antagonist (Coumadin), or low-molecular-weight heparin (Lovenox). Direct-acting (novel) oral anticoagulants should be avoided as they have not been studied extensively in valvular AF. (1-6) Percutaneous balloon valvotomy may be considered in selected patients in whom medical management has failed and the patient continues to be symptomatic with evidence of pulmonary edema, provided the anatomy is feasible and there are no LA/LV clots or presence of more than mild MR (Figure 6-1).
Algorithm for management of valvular heart disease (VHD) in COVID patients. GDMT, guideline-directed medical therapy.