The impact of COVID-19 pandemic on interventional cardiologists in training

A prospective online European survey

Authors

Marco Toselli¹, Alessio Mattesini², Arif Khokhar¹, Alessandro Sticchi^1,Antonio Mangieri¹, Maria Piera Capranzano³, Salvatore Brugaletta⁴, Andreas Baumbach⁵, Fabio Tarantino⁶, Giuseppe Tarantini⁷, Gianluca Campo^1,8, Antonio Colombo¹, Francesco Giannini¹

Introduction

Since December 2019, a progressive escalation of cases of Corona-virus disease (COVID-19) has been registered worldwide¹. This pandemic has significantly impacted healthcare systems. Interventional cardiology units have overseen a dramatic reduction in elective and urgent interventional procedures^2,3. The reduction of the procedures has determined the reorganization of the cath lab activities. Interventional cardiologists in training (ICTs) have consequently experienced an impact on their learning curve⁴ due to the reduction of the procedures number and the possible reallocation in COVID-19 units.

The impact of the pandemic on ICTs has not been fully elucidated. We, therefore, decided to create a survey tailored for ICTs in order to assess the changes in their training. Capturing the essence of the responses may help to identify the most appropriate strategies to provide the highest standards and skills achievements in COVID-19 era.

Methods

We performed a prospective online survey to assess the impact of COVID-19 pandemic on ICTs in Europe. The initiative has been supported and delivered by the Italian Society of Interventional Cardiology (GISE) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI Young) to under 40-year-old members from April 15th to May 5th. The questionnaire consisted of 37 multiple-choice questions, divided into four main topics:

1. ICT’s general information,
2. impact on interventional training,
3. COVID-19 related training
4. ICT’s perspectives for the near future.

The answers were anonymous and are summarized in Table 1. All the survey participants expressed their consent to the publication of the answers.

Table 1 - Data in brief regarding ICTs demographic characteristics and main questions of the survey

GENERAL INFORMATION
Sex (%) Male/ Female	86.2 / 13.8
ITC clinical role (%) Fellow Resident PhD Attending Others	32.8 28.2 9.8 21.3 7.9
The ICT has been infected by COVID-19 (%) Yes /No / Maybe	2.9 / 85.1 / 12.1
CORONARY/STRUCTURAL TRAINING
Modification of the ICT training due to the pandemic (%)	62.5
Reduction rate of the Cath lab training since March 2020 (%) 0-25% / 25-50% / 50-75% / 75-100%	13.2 / 24.3 / 34.7 / 27.8
Adopted strategies to balance the training gap (%) Conference calls Clinical and laboratory research Shift to COVID-19 units Differentiated shifts Simulation workshops	32.0 28.0 25.0 12.0 3.0
Reduction of the involvement in the procedures by the tutor in order to become more time-efficient and/or spare PPE (%)	56.6
Renunciation to a training period abroad	27.0%
COVID-19 RELATED TRAINING
The Institution has provided training on the use of PPE (%) No Yes, documents / practical courses / meetings	11.5 48.3 / 23.0 / 17.2
Available PPE in the Cath Lab (multiple choices allowed) (%) Masks / gloves / goggles Disposable face shields / Long-sleeved isolation gowns All of them	51.2 / 50.0 / 36.6 36.6 / 33.1 66.3
Sensation of safety working in the Cath-Lab during Covid-19 pandemic (0= extremely unsafe; 5= extremely safe) (%) ≤2 ≥3	17.7 82.3
Thrombolysis administration rate in STEMI during the pandemic (%) Never / <1% / 1-5% / >5%	68.2 / 17.9 / 8.1 / 5.8
The Institution has provided training on the use of oxygen delivery/ventilation systems (%) No Yes, documents / practical courses / meetings	46.8 29.0 / 15.2 / 9.0
ICT PERSPECTIVES FOR NEAR FUTURE
Impact duration of the pandemic on the training (%) 1 more month 1-3 months / 3-6 months / 6-12 months >1 year	3.8 30.8 / 34.0 / 23.1 8.3
Possible future role of telemedicine in ICTs’ training (%)	89
Future strategies to overcome the current training gap (%) Extending the training period Increasing the number of hand-on and theoretical courses Asking for a re-assignment to a COVID-19 free hospital, if possible Other	56.8 27.3 3.0 12.9

Results

General information

A total of 174 ICTs (86.2% men; mean age of 33.5±5.7 years) participated in the survey. ICTs were from 23 European countries. ICTs were fellows in 32.8% of the cases, residents in 28.2%, attendings in 21.3% and PhD students in 9.8%. The majority of the participants (85.6%) worked in hospitals with COVID-19 patients. Of the 57.5% of ICTs tested for the virus, 2.9% were positive for COVID-19.

Impact on interventional training

Globally, 61.6% of the responders reported a modification of the training as a result of the pandemic: 62.5% revealed a >50% reduction since the beginning of March. The main reason, reported by 98.9%, was a reduction of urgent and elective coronary and structural procedures. In more than half of the cases (56.6%), the decrease was attributed to the choice of senior operators to spare personal protection equipment (PPE) and be more time-efficient.

Alternative strategies to the cath lab training were reported to be conference calls or clinical/laboratory research in 32% and 28% of the cases, respectively. One out of four ICTs discontinued the training because of reassignment to a COVID-19 unit. ICTs experienced not only a training gap in their institutions, but they also renounced to a training period abroad (fellowship and/or course) in 74.3%.

COVID-19 related training

Considering the elevated risk of exposure and the high prevalence of cardiovascular manifestations related to COVID-19⁵, it is advisable to provide specific training to all ICTs. Indeed, 88.5% of ICTs received instructions on the use of personal protection equipment (PPE), including documents, practical courses or meetings. One third (33.7%) of the participants reported to a lack of availability of a full PPE equipment in the cath lab. Despite the necessity of intensive care support in positive patients, only 53.2% of the participants received specific instructions regarding the use of oxygen delivery/ventilation systems.

Finally, STEMI protocols have changed during the pandemic as revealed by 63% of the ICTs: indeed, 31.8% of the ICTs reported thrombolysis administration at least once during their clinical activity.

ICT’s perspectives for the near future

According to the ICTs, the COVID-19 pandemic will probably impact the training for further 3-6 months (57.1%) or even for one more year (8.3%). In order to address this issue, 56.8% of participants proposed to extend the training period, 27.3% to increase the number of hands-on or theoretical courses or to ask for a re-assignment to a COVID-19 free hospital (3.0%). The vast majority (89%) suggested that telemedicine could play a relevant role in training for interventional cardiology in the future.

Discussion

This survey highlighted multiple relevant points:

1. an overall reduction of the cath lab activity and the ICTs’ training;
2. the adoption of alternative strategies of training in order to deal with the lack of hands-on practice;
3. a low level of specific training on the use of PPE and oxygen delivery/ventilation systems.

During the COVID-19 pandemic, cath lab activities have experienced a deep reorganization: elective procedures have been stopped or postponed, and urgent cases decreased significantly due to the infective risk². It is noteworthy that STEMI protocols and clinical scenarios have changed in the majority of hospitals. More frequent use of thrombolysis even in hub centres was reported by 31.8% of the participants in order to reduce the infective spreading. Furthermore, an increased number of late presented or/and complicated myocardial infarctions has been registered worldwide, reflecting the patients’ fear of a nosocomial source of infection.

According to our results, ICTs have decided to dedicate more time to clinical and laboratory research; conference calls, online meetings/congresses and journal clubs have become a consolidate way to share knowledge avoiding personal contact. However, these activities may provide theoretical knowledge but can not entirely replace the hands-on activities. The prolongation of the training period has been widely required by the participants (56.8%) in order to fill the gap: an extension of the common twelve months training should be probably planned in the institutions. The survey pointed out another relevant issue: virus spreading has also limited abroad fellowships programs, a recognized opportunity to complete the training and to attend an international environment.

Considering the elevated risk of exposure and the high prevalence of cardiovascular manifestations in COVID-19, the survey detected a lack of specific instructions on the management of respiratory failure, including oxygen delivery/ventilation systems. We believe that ICTs may benefit from training on intensive care support that represents life-long expertise for their practice, even after COVID-19 era.

Telemedicine appeared to be a possible strategy to manage specific issues of the patients care as reported by the vast majority (89%) of the responders. Patients follow-up, heart rate and rhythm monitoring are possible fields of application, but legal issues and insurance reimbursement are still open questions. From an educational point of view, the availability of a growing number of live or on-demand virtual meetings/webinars represents an advantage to share contents, live cases and expert opinions with the least waste of time and contagious risk.

Limitation

The limitations of the present study are the relatively small sample size of ICTs and the data collection from different European countries with heterogeneous pandemic peaks. Moreover, the survey was only addressed to the members of GISE and EAPCI societies. However, our data remain valuable as they represent the largest survey assessing the impact of the COVID-19 pandemic on ICTs learning curve. As with all surveys, particularly those with multiple-choice questions, the results may be biased by the opinion of the investigators who wrote the questions.

Conclusion

The training phase is crucial for ICTs’ career and their training in Europe has been significantly impacted by COVID-19. A point of major concern will be the adoption of specific strategies in the near future to fill in the ICTs’ training gap. Institution and mentors have to find proper ways to guarantee skills achievements but dealing with COVID-19 outbreak. Determining critical points in the ICTs programs may help to identify the most appropriate strategies to provide the highest standards of education in the COVID-19 era.

Impact on daily practice

Interventional cardiology training in Europe has been significantly impacted by COVID-19.

Acknowledgements

We thank GISE team for the support and the survey delivery.
We thank EAPCI team for the support and the young EAPCI ambassador (Dr Pedro Carrilho Ferreira, Dr Mukhtar Kulimbet, Dr Milorad Tesic, Dr Kyriakos Dimitriadis, Dr Mariama Akodad, Dr Gustavo N. Araujo, Dr Mark Kennedy, Dr Radoslaw Parma, Dr Lucian Predescu, Dr Mikko Minkkinen) for the survey delivery.

References   

1. Grasselli, G., Zangrillo, A., Zanella, A., Antonelli, M., Cabrini, L., Castelli, A., Cereda, D., Coluccello, A., Foti, G., Fumagalli, R., Iotti, G., Latronico, N., Lorini, L., Merler, S., Natalini, G., Piatti, A., Ranieri, M.V., Scandroglio, A.M., Storti, E., Cecconi, M., Pesenti, A., for the COVID-19 Lombardy ICU Network, 2020. Baseline Characteristics and outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA 323, 1574.
2. De Filippo, O., D’Ascenzo, F., Angelini, F., Bocchino, P.P., Conrotto, F., Saglietto, A., Secco, G.G., Campo, G., Gallone, G., Verardi, R., Gaido, L., Iannaccone, M., Galvani, M., Ugo, F., Barbero, U., Infantino, V., Olivotti, L., Mennuni, M., Gili, S., Infusino, F., Vercellino, M., Zucchetti, O., Casella, G., Giammaria, M., Boccuzzi, G., Tolomeo, P., Doronzo, B., Senatore, G., Grosso Marra, W., Rognoni, A., Trabattoni, D., Franchin, L., Borin, A., Bruno, F., Galluzzo, A., Gambino, A., Nicolino, A., Truffa Giachet, A., Sardella, G., Fedele, F., Monticone, S., Montefusco, A., Omedè, P., Pennone, M., Patti, G., Mancone, M., De Ferrari, G.M., 2020. Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy. N. Engl. J. Med. NEJMc2009166. 
3. Roffi, M., Capodanno, D., Windecker, S., Baumbach, A., Dudek, D., 2020. Impact of the COVID-19 pandemic on interventional cardiology practice: results of the EAPCI survey. EuroIntervention 16, 247–250. 
4. Sinha, S.S., Sharma, G., Cullen, M.W., 2020. The Crucible of Crisis. J. Am. Coll. Cardiol. S0735109720349147. 
5. Bonow, R.O., Fonarow, G.C., O’Gara, P.T., Yancy, C.W., 2020. Association of Coronavirus Disease 2019 (COVID-19) With Myocardial Injury and Mortality. JAMA Cardiol.  

Conflicts of interest

The authors have no conflicts of interest to declare

Affiliations

1. GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
2. Division of Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy.
3. Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy.
4. Institut Clinic Cardiovascular (ICCV), Hospital Clinic i Provincial de Barcelona (HCPB), Barcelona, Spain.
5. Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
6. Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.
7. Department of Cardiac, Thoracic, Vascular Sciences, University of Padua, Padua, Italy.
8. Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.