DISCUSSION
In the current COVID-19-pandemic, it is important to rule out an infection with COVID-19 in patients undergoing cardiac surgery to prevent complications from COVID-19 infection for a variety of reasons—for example, there is currently no available information on how these patients tolerate cardiopulmonary bypass. For this reason and to ensure the availability of intensive care unit (ICU) beds, most countries recommend postponing elective surgeries or interventions as much as possible. In our patient, the CT scan with interstitial infiltration was highly suspicious for a COVID-19 infection that was confirmed by three independent radiologists. In contrast, two consecutive PCR tests returned negative. Recently, it has been discussed that PCR testing might be inferior to CT scans to detect infections as the average time between initial negative and positive reverse transcription polymerase chain reaction test results in patients who already display signs of infection on CT scans is 5.1 ± 1.5 days [2].
In the patient described above, our dilemma was that clinical symptoms, increasing bilateral pleural effusion and a rise in proBNP indicated impending cardiac failure. At the same time, COVID-19-associated pneumonia was still a possibility. As the intended waiting interval of 2 weeks to increase certainty concerning the infectious state could not be achieved due to the patient’s cardiac condition, immediate treatment was necessary. Following discussion in the local heart team and with the consent of the patient, we decided to perform valve-in-valve transcatheter aortic valve replacement (TAVR) to prevent the potential complications of a prolonged re-root-replacement with its long operative and cardiopulmonary bypass times, which could lead to an increased time on the respirator in the ICU. The decision was made even though the patient was only 57 years old and would have undergone an open surgical procedure under normal circumstances, especially as there is limited information available on the durability of TAVR valves [3]. Due to our extensive experience with valve-in-valve-TAVR into degenerated Freestyle-prostheses (>40 cases), we decided to use a SAPIEN S3 (Edwards Lifesciences Corp. Irvine, CA, USA), which facilitates reoperation and preserves the access to the coronary arteries, which is of importance in a young patient. We also decided to perform the procedure under general anaesthesia and to intubate the patient as we intended to perform intraoperative transoesophageal echocardiography and wanted to avoid the risk of an emergency intubation during the procedure, which would pose a higher risk of infection for the whole team than an intubation under normal conditions.