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