Cardiac CT may be safer vs. TEE during COVID-19 pandemic

Cardiac CT may be the ideal imaging technique during the COVID-19 pandemic compared with transesophageal echocardiography, according to a presentation at the Society of Cardiovascular Computed Tomography Annual Scientific Meeting.

“The COVID-19 pandemic has affected and upended everything that we do in delivering cardiovascular care,” Andrew D. Choi, MD, FSCCT, co-director of cardiac CT and MRI, interventional echocardiographer and associate professor of medicine and radiology at George Washington University School of Medicine, said during the presentation.

Recent guidance documents

The Society of Cardiovascular Computed Tomography published a guidance document in the Journal of Cardiovascular Computed Tomography in March focused on the use of cardiac CT and cardiac imaging during the pandemic. Since then, it has been updated several times to address other issues like myocardial injury, possible ACS, pediatric congenital heart disease and safe reintroduction of CV services.

“It was meant to be a living guideline or a living guidance document so that as the pandemic has evolved over the last couple of months, we as a society would evolve and be able to address the needs of our patients,” Choi said.

In June, the editors of JACC: Cardiovascular Imaging and the American College of Cardiology Imaging Council developed and published a guidance document that gives a comprehensive multimodality view. This document takes pandemic phases into consideration.

“As we’ve been at the peak of this pandemic, the use of imaging and CT was minimized so it would only be in those patients in which management was impacted and to be able to keep not only patients but physicians and providers safe,” Choi said. “The hope is that as more places go into more of a deceleration phase, that we’d be able to resume cardiac CT imaging to enable diagnosis, prevention, long-term management as well as prognosis.”

During the pandemic, worldwide cardiac testing has decreased by 50% to 90%, according to the presentation. This decrease in testing may present diagnosis and prognostication and may contribute to an increase in morbidity.

Cardiac CT should be considered compared with transesophageal echocardiography (TEE), especially since aerosol-generating procedures can spread the virus and pose a risk for echocardiographers, personnel and patients. The ideal CV imaging modality during the pandemic should be used for urgent indications for patients with symptoms, should reduce the use of personal protective equipment (PPE) and resources, and is accurate and can allow for change in management.

Although cardiac CT may lead to droplet and contact exposure, there is more distance between staff and patients compared with other imaging procedures. PPE when performing cardiac CT on patients without COVID-19 symptoms should include a surgical mask and gloves. For patients with confirmed, suspected or are recovering from COVID-19, PPE should include a surgical mask, face shield, gown and gloves. In contrast, PPE for TEE for patients without COVID-19 should include an N95 mask, face shield and gloves, whereas the same PPE would be required for this procedure as for cardiac CT for patients with COVID-19.

Another reason to consider cardiac CT compared with TEE is that the latter may lead to new injury. In a study published in the Journal of the American College of Cardiology this year, researchers found that 86% of patients who underwent TEE during structural cardiac interventions had new injury, 40% of which were complex lesions.

“It highlights what has been suspected and known from surgical literature that while TEE as a procedure is incredibly important particularly in the interventional space — it’s something that I do — we need to be mindful of some of these risks that are associated with it,” Choi said.

Advantages of cardiac CT

Some of the advantages of cardiac CT include high spatial resolution and it allows for full 3D reconstruction. This is also ideal for patients with esophageal or gastric disease, those who are frail, and patients with pulmonary hypertension or lung disease. Importantly, especially during the pandemic, cardiac CT can enable a reduction in PPE use and resource utilization.

Some indications for cardiac CT include the assessment of left atrial appendage, endocarditis, invasive complications and prosthetic valve dysfunction, according to the presentation.

Choi said these considerations for cardiac CT should continue after the pandemic subsides.

“While utilization might revert back to usual practice post-pandemic, I hope … that highly efficient, cost-effective and accurate CT approaches should ideally remain the first line of care,” Choi said.

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