Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology

Coronavirus disease 2019 has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways. (J Am Coll Cardiol EP 2020;6:1053-66)
which has seen great regional variability in surge volumes, incidence curve flattening, and outcomes. As stay-at-home orders are lifted and businesses reopen, concerns remain regarding the prospect of secondary peaks in disease incidence and the possibility of a continuation or expansion of existing restrictions of clinical services. It is likely that the global pandemic will continue to exert significant effects until resistance to the pathogen is developed through vaccination, herd immunity, or discovery of definitive therapy.
The degree to which patient outcomes have been adversely impacted by delaying the delivery of usual cardiac care, due to resource limitations and/or patient reluctance, is not fully understood. Early data have suggested that cardiac patients presenting with a myocardial infarction or experiencing heart failure may be suffering worse outcomes due to delayed presentations [bib_ref] Secondary impact of the COVID-19 pandemic on patients with heart failure, Reza [/bib_ref] [bib_ref] Heart failure in the COVID-19 pandemic: where has all New York's congestion..., Barghash [/bib_ref]. Many chronic diseases and acute medical conditions often require a nonurgent, but time-sensitive, intervention to prevent them from becoming emergencies or having long-term sequelae.
Questions remain as to how long one can delay these nonurgent medical interventions to prevent patients from developing undesirable outcomes. Given these remaining shortcomings and the still undetermined course of the pandemic, there is uncertainty as to how to resume effectively and deliver much-needed electrophysiology (EP) services for non-COVID-19 arrhythmia patients. COVID-19 will continue to coexist and present significant health care delivery challenges. Many patients remain fearful about exposure in health care settings [bib_ref] Secondary impact of the COVID-19 pandemic on patients with heart failure, Reza [/bib_ref].
Creating a relatively COVID-19 safe clinical care continuum and environment is an important strategy that can regain patient confidence and enable health care institutions to start providing elective cardiovascular (7) and EP procedures. "Rebooting" EP at many institutions may be more challenging than

## Covid-19 ep reboot
A U G U S T 2 0 2 0 : 1 0 5 3 - severely affected, where entire hospitals were converted into COVID-19 care units, will likely require a longer time before they will have capacity to provide care for non-COVID-19, nonurgent cases. However, this may be quite different for regions that are less affected and have a significantly lower prevalence and incidence of COVID-19 cases. In general, a significant and sustained drop in local incidence should be observed before health care organizations in areas experiencing a high case level should increase elective medical interventions. The timing and rollout of this process will be dictated by governmental and health system policies. In areas fortunate enough to have avoided a high COVID-19 burden, assiduous attention to ongoing local COVID-19 incidence will be essential to managing the reboot process and the need to respond rapidly if a second wave occurs.
Accordingly, resumption of nonurgent EP services should be approached in a measured and cautious manner. Contingency plans and specific criteria to limit or stop elective cases in the event of a second wave should be predefined in advance of reopening in compliance with local regulations.

## Role of screening and

## Diagnostic viral testing
Testing for COVID-19 infection is a critical tool as we embark on safely restarting elective and semi-elective procedures. Patient screening and diagnostic testing are important tools to limit patient and staff exposure.
However, lack of widespread access to timely and accurate viral testing has been a major limitation from the onset of the pandemic [bib_ref] Overcoming the bottleneck to widespread testing: A rapid review of nucleic acid..., Esbin [/bib_ref] , and there will likely be persistent variations in regional availability of testing, greatly affecting our ability to identify infected individuals, schedule cases, prevent disease transmission, and clarify policies that will minimize the risk of restarting elective procedures. DEVELOPING TESTING POLICIES FOR EP CARE. A major concern inhibiting patients from coming to hospitals is the fear of contracting COVID-19, as both patients and HCWs can be asymptomatic carriers with the potential to infect other patients and health care staff [bib_ref] Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2), Li [/bib_ref]. The availability and implementation of universal testing policies for patients prior to procedures and for HCWs, as well as universal masking, sanitization, and hand hygiene, can favorably impact confidence.
Institutions will need to define standardized and comprehensive protocols for testing, including testing prior to planned procedures. Electrophysiologists, laboratory managers, and outpatient clinical team leaders should define workflow processes for preprocedure testing and operational plans concordant with hospital and local policies. For many institutions, testing policies will be extensive and include multiple locations, such as clinics, procedural areas (eg, cardiac catheterization laboratory, endoscopy suite, interventional radiology suite, etc), and off-site locations (including drive-through testing). Accommodations to testing will need to be based on a patient's clinical condition, geographic location, inpatient versus outpatient status, type and urgency of intervention, test capability, and local conditions.
Ideally, viral PCR testing should be performed

## Covid-19 ep reboot
A U G U S T 2 0 2 0 : 1 0 5 3 - Postoperative or postprocedure COVID-19 testing may need to be considered in patients who develop symptoms after the procedure is performed. Atelectasis, fever, and volume overload are not uncommon in the postoperative period. Establishing operational guidelines for COVID-19 testing in these patients and management of testing results should be determined.

## Testing and return to work for health care workers
Transmission of COVID-19 to exposed HCWs has been documented. Since a negative test does not preclude subsequent infection, even soon after testing, periodic viral testing for asymptomatic HCWs is not currently a standard approach, but enhanced surveillance of IgG serology. Where available, viral testing should be performed to help determine whether the HCW is in true convalescence without active viral shedding. Some institutions offer serology testing for HCWs, which may suggest exposure to coronavirus, but whether antibodies confer immunity to recurrent infection is unproven.

## Risk stratification and

## Management strategies based on

## Covid-19 disease burden
The ability to perform elective or semi-elective cases is highly dependent on the COVID-19 burden in each region. Regional risk can be categorized based on the severity of disease burden, the state of resource utilization, and projections [fig_ref] FIGURE 3: Framework [/fig_ref] , as follows: 1) high prevalence and incidence, 2) medium prevalence and incidence, and 3) low prevalence and incidence.
These factors could impact whether the health care systems in a region have the capacity to start engaging in elective procedural or medical care. Type of procedures to be restarted (see 
[formula] - Urgent/emergent - Urgent/emergent - Priorized semi-elecve, me- sensive - Urgent/emergent - Priorized semi-elecve, me-sensive - Semi-elecve, [/formula]

## In-person cied interrogation
Depending on the regional stage of the pandemic, local, hospital, and departmental guidance may vary.
In regions with continuing concern for pandemic spread, in order to minimize exposure of EP staff and device manufacturer representatives to patients with

## Covid-19 ep reboot
A U G U S T 2 0 2 0 : 1 0 5 3 - Potential strategies to maintain social distancing include reconfiguring waiting areas and/or notifying patients when it is time for them to be seen. Importantly, device interrogation programmers, cables, and wands should be disinfected between all patients.
Plastic sleeves to cover the cable and wand may also be considered. It may be helpful to inform patients of the disinfecting procedures being systematically performed between visits.

## Remote device monitoring
A current expert consensus statement gives remote monitoring a class I recommendation for routine use in patients with CIEDs (22) based on multiple studies demonstrating reduction of unnecessary ICD therapies and mortality [bib_ref] HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable..., Slotwiner [/bib_ref] [bib_ref] Use of remote monitoring of newly implanted cardioverterdefibrillators: Insights from the patient..., Akar [/bib_ref] [bib_ref] Impact of remote monitoring on clinical events and associated health care utilization:..., Piccini [/bib_ref]. Despite its effectiveness, prior to the pandemic, remote monitoring was significantly underutilized due to a variety of patientand system-based issues [bib_ref] Use of remote monitoring of newly implanted cardioverterdefibrillators: Insights from the patient..., Akar [/bib_ref]. During the pandemic, use of remote monitoring is even more important and should be used in most circumstances to reduce the need for nonurgent clinic visits. When feasible, remote monitoring should be reconsidered in patients who are currently not enrolled.

## Creating relatively covid-19 safe ep care pathways
Quality improvement programs and care pathways can help to standardize and support safe, highquality, high-value patient care. Risk-adjusted data can be used to evaluate patient care outcomes. Based on principles discussed, an example of a stepwise care pathway is summarized as follows :
Step 1: Initial consultation for an intervention

## -post-discharge period
Update the workflow based on tes ng availability and na onal, regional, and ins tu onal guidelines
- Preauthoriza on consent and documenta on

## -preopera ve period

## Covid-19 ep reboot
A U G U S T 2 0 2 0 : 1 0 5 3 -6 6
Step 5: Post-discharge period
[fig] Figure 1: illustrates a model for the evolution of detectable virus and virus-specific immunoglobulin during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Our current understanding regarding the limitations of these tests and how the timing of results over the course of exposure or infection impacts the interpretation of test results are shown in Figure 2. [/fig]
[fig] FIGURE 2: The Differences Between Polymerase Chain Reaction (PCR) and Serologic Testing as Well as Features and Limitations That Need to Be Understood Prior to Using Them and Incorporating Them Into the Reboot Testing and Workflow [/fig]
[fig] FIGURE 3: Framework [/fig]
[fig] : Obtain proper consent with paents understanding the medical necessity and the risks of COVID-19 infecon; this may require documentaon in the medical record Be facile to adjust priorizaon if incidence rates indicate a second wave(s) High Severity of disease burden Medium Low The ultimate decision regarding the time sensitivity of a procedure is based on clinical judgment and individual patient factors. AF 14 atrial fibrillation; AFL 14 atrial flutter; AV 14 atrioventricular; AVB 14 atrioventricular block; CHB 14 complete heart block; CIED 14 cardiac implantable electronic device; CRT 14 cardiac resynchronization therapy; CT 14 computed tomography; EOS 14 end of service; EP 14 electrophysiology; ERI 14 elective replacement indicator; HF 14 heart failure; ICD 14 implantable cardioverter defibrillator; LAA 14 left atrial appendage; PM 14 pacemaker; PVC 14 premature ventricular contractions; RVR 14 rapid ventricular response; SND 14 sinus node dysfunction; SVT 14 supraventricular tachycardia; TEE 14 transesophageal echocardiography; VT 14 ventricular tachycardia; WPW 14 Wolff-Parkinson-White. [/fig]