INTRODUCTION
In late December 2019, the Chinese Center for Disease Control and
Prevention initiated an investigation of patients with a respiratory
illness of unknown etiology in Wuhan.1 The causative
pathogen was a new coronavirus, severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), and the disease was designated coronavirus
disease 2019, or COVID-19. Two salient features were an overall
case-fatality rate of 2.3% and fast geographical
dissemination.2 It was stated, “COVID-19 rapidly
spread from a single city to the entire country in just 30 days.” The
initial cluster was theorized to be due to zoonotic transmission from a
seafood and wet animal wholesale market. Subsequent person-to-person
transmission is believed to occur in a similar fashion to SARS-CoV-1,
which caused the SARS outbreak in 2003.3,4 This
involves contact with infected respiratory droplets, aerosols, and
fomites.
In the United States of America, patient zero was a 35-year-old man who
presented to an urgent care clinic in the State of Washington on January
19, 2020 after visiting Wuhan.5 Given the trajectory
of cases and the impending pandemic, the Centers for Disease Control and
Prevention (CDC) suggested on February 29 that inpatient facilities
should “Reschedule elective surgeries as
necessary.”6 On March 13, the American College of
Surgeons recommended that every “hospital, health system, and surgeon
should thoughtfully review all scheduled elective procedures with a plan
to minimize, postpone, or cancel electively scheduled operations,
endoscopies, or other invasive procedures until we have passed the
predicted inflection point in the exposure graph and can be confident
that our health care infrastructure can support a potentially rapid and
overwhelming uptick in critical patient care needs.”7Vice Admiral Jerome M. Adams, MD, the Surgeon General, concurred. On
March 18, the Centers for Medicare & Medicaid Services (CMS) issued
“guidance to limit non-essential adult elective surgery and medical and
surgical procedures” and referenced the Elective Surgery Acuity
Scale.8
On March 20, a Heart Rhythm Society (HRS) COVID-19 Task Force message
agreed with “CDC recommendations to postpone elective EP
procedures.”9 It continued, “Elective procedures may
include, but are not limited to, ablation in clinically stable patients,
device upgrades, most primary prevention ICD implants, left atrial
appendage closure device implants, and implantable loop recorders.” On
March 31, a guidance paper was published by the HRS COVID-19 Task Force,
the American College of Cardiology (ACC) Electrophysiology Council, and
the American Heart Association (AHA) Electrocardiography and Arrhythmias
Committee.10 It divided invasive cardiac
electrophysiology procedures into three tiers: 1) urgent/non-elective,
2) semi-urgent, and 3) non-urgent/elective. The purpose of this
manuscript is to provide a priority plan for invasive cardiac
electrophysiology procedures during the COVID-19 pandemic that is
consistent with, yet simplified in comparison to, prior
recommendations.6-10