Top Talks | Post the COVID-19, cardiovascular disease diagnosis and treatment still has a long way to go!

The COVID-19 epidemic has brought great challenges to the world. What impact does it have on the diagnosis and treatment of cardiovascular disease patients? During the epidemic, how should interventional doctors perform percutaneous coronary intervention (PCI) surgery? In response to this series of issues, this journal invites Prof. Stephan Achenbach, President of the European Society of Cardiology (ESC), Prof. Zhou Yujie and Dr. Gao Fei from Beijing Anzhen Hospital of Capital Medical University, and Prof. Qian Jie from Fuwai Hospital of the Chinese Academy of Medical Sciences to discuss related questions online.

Prof. Zhou: I want to know about the COVID situation in your country. How does it affect patients undergoing PCI and interventional cardiologists?

Prof. Achenbach:The situation in Germany as far as COVID-19 is concerned is somewhere in the middle. In Europe, we had the first wave in March/April/May of this year, and a second wave started around October. Compared to other countries in terms of rates of infection and rates of hospitalizations, Germany has been lower than other countries. Still, it does affect our healthcare system. We currently have around 60 patients with COVID-19 in our hospital, twenty of those in the intensive care unit on ventilators. Our hospital is in a relatively small city, which is why our numbers are not so big. Fortunately, the German healthcare system is not overwhelmed. We can still take care of all the patients who need medical help. Our PCI, our structural heart, and our electrophysiology volume is not affected. We have to be very rational about using our resources; even more rationally, by moving patients faster than we usually do, because we have lost some beds to COVID wards. But we can do everything that needs to be done. In the first wave, we saw that patients were staying at home rather than coming to the hospital, because they were afraid that they might get infected when being in the hospital, but now in this second wave, the population has become better informed. The one thing we do when a patient comes in with an acute coronary syndrome and has even the slightest signs of a respiratory infection, is we cath in protective equipment, which of course is a little more cumbersome, but absolutely do-able. So that is the only thing that really affects us though. 

Prof. Zhou: Our hospitals are cardiovascular disease hospitals and in the early stages of the pandemic we often discussed performing PCI on COVID-19 patients. Now in Beijing, we have negative-pressure transport vehicles and negative-pressure wards to protect patients and doctors in infectious diseases hospitals. Now we don’t have many COVID patients in Beijing, but we are prepared for later waves. We have seen cases imported from North America and Europe however. We are equipped with a negative-pressure cathlab for COVID-positive patients, but we haven’t had much opportunity to use these facilities. What about you, Dr Qian?

Prof. Qian: At our hospital, we don’t have this capability at the moment as we are purely a cardiac center. If we were to be presented with a COVID-positive patient, we would probably not perform primary PCI, but according to our hospital’s protocols, we would transfer the patient, maybe to your hospital. But I believe Germany has good control. Dr Achenbach, how do you and your colleagues control COVID-19 without overwhelming your medical resources, keep medical staff relatively safe and maintain the volume of usual work as you have said?

Prof. Achenbach:There are three reasons why we think Germany is doing relatively well in this COVID-19 pandemic. Number one, we have a very effective public health system. In every city we have public health offices and they trace all the positive patients and their contacts and tell them to stay at home and in quarantine. This has been more effective than in other countries in keeping the chain of infection under control. Number two is of course that our population in Germany is relatively disciplined. This differs between nations and in Germany, its citizens are relatively disciplined and follow public health orders. Our politicians introduced measures fairly early. Even though measures were not very strict, they were applied early, such as wearing masks in public, which was not something that usually occurred in Europe. That was helpful. Thirdly, we are lucky because we have a lot of hospital capacity. Germany is often criticized because we have three-times more intensive care beds and three-times more normal beds than other countries per head of population. Of course, now this has been to our advantage. 

Prof. Zhou: We hear that your public health system is very good and your citizens very disciplined, which is needed in the coordination of  a pandemic response. 

Prof. Achenbach: What hasn’t worked well is the app. The Germans don’t like the app. We have an app that can trace contacts, but Germans are very reluctant to use it, due to data protection concerns, so this does not work so well in Germany. But the public health offices are very effective.

Prof. Zhou:  What about your experience, Dr Gao?

Dr. Gao : As the Professor mentioned, apps and smartphones have had limited success in Germany, but in our country, digital devices have made a great contribution to the control of COVID-19. In our hospital, we have apps for patients as well as for doctors. Each doctor has to report their health condition, and if they have travelled to high-risk areas, they need to report their footprints via the smartphones to authorities. Before arriving at a hospital, patients have to use their smartphone to trace their footprints to determine if they have been in a high-risk area. I think the smart devices have helped us to a large extent to control virus spread, and to enforce some discipline on patients and doctors to keep everyone safe. 

Prof. Achenbach: The German government tried to introduce this technology and the apps are available, but the population is reluctant to use it. 

Prof. Qian: Dr Achenbach, how are you able to deal with very severe COVID patients in your center? It is tough. This requires a lot of medical staff and resources. 

Prof. Achenbach: Luckily, we have all of this available. In our hospital we can maintain 130 patients on respirators. The hospital has 1300 beds, and we can turn 10% of them into intensive care beds with respirators. We also have ECMO (extracorporeal membrane oxygenation) available. We have taken patients from other hospitals on ECMO so we can try to stabilize them. Of course, the mortality rate is not low in patients with severe disease. Currently, our infrastructure allows us to manage this, and this what our politicians are aiming for - to keep infection rates so low (zero rates are not possible) using public health measures that our hospital system will never be overwhelmed. That is the strategy. Of course, we are hoping for a vaccine. It looks like the first vaccinations will start mid-December here in Germany. 

Prof. Zhou: One of the impacts of COVID-19 is that many medical conferences have been held online. What are your thoughts on online medical conferences in the future?

Prof. Achenbach: This is a very interesting topic. In Germany, all medical meetings and other conferences have become virtual. Our hospital doesn’t allow any meetings. Our professional societies don’t do any meetings anymore; they are all online. Physicians are not even allowed to travel; they have to stay in their hospital. I am in a specifically difficult position because I am the President of the European Society of Cardiology (ESC), and the ESC has very big meetings. Our largest meeting is the ESC Congress which typically has around 30000 participants, but this year we cancelled the on-site meeting and turned it into an online event. We had 120000 participants - four times more than usual. We can reach countries that typically can’t attend our Congress, like Colombia, Venezuela and so on, with our online Congress. This is the model of the future. I am convinced that in the future, after a transition phase, individuals will have become so used to using the online infrastructure that congresses will have two branches. There will be an on-site component because people want to meet and travel, and to see, hear, smell, touch and experience a conference, and at the same time, the congresses will be designed so they can easily be transmitted on the internet. This doesn’t work with the traditional format (90 minute session/15 minute break/another 90 minute session). This way it can become faster, more adaptive. So we would have two components - online and on-site. In some respects, online is even better. The visuals are always perfect. You can always see the slides. You can have a cup of coffee. You can switch off for a while. Go for a walk and come back. The on-site congress will cultivate the experience - the fun and the excitement, interactions, retention of memories because you were there. The online experience will be very educational. I am convinced of this. 

Prof. Qian: I agree. COVID-19 will change our lifestyle and the world. 

Prof. Achenbach:Certainly accelerated change. I am convinced of that. 

Prof. Qian: In the past, we would travel to different places and provinces in China for local medical meetings and national conferences. It would be very busy. For the last ten months, we have had little chance to attend such meetings and then only online. Even now, from my living room with my family or from my office, we can spend time talking about medicine. It has been very interesting. 

Prof. Achenbach: I totally agree. We can present talks in four different countries in one day now via the internet with a large audience. 

Prof. Qian: With advancing internet technology, doctors in smaller local Chinese hospitals can get guidance to perform operations and to introduce new techniques in the field of interventional cardiology. 

Prof. Achenbach: We have done the first robotic PCIs here in Germany. We can imagine that remote operations will become much more feasible than they have in the past. Personally, I prefer to do it there with my own hands on the patient, but it is not about personal preference but what is best for the patient. 

Prof. Zhou: Recently, I have received invitations to attend seminars and meetings, but unless I am performing a procedure, I am really reluctant to fly. I will always choose to be online now. I have still attended a few meetings and it’s a large room with a few monitors and a lower quality experience. 

Prof. Achenbach: Just a few years ago, an online event wouldn’t work well - intermittent and poor sound quality, poor image - but now we all have nice cameras, good lighting and good microphones. Techniques have got much better. Not a revolution, but certainly an evolution. Things have got a lot better making the online experience more accessible. We are well equipped now to deliver and receive high quality online education. 

Prof. Qian:As the President of ESC, how will you design next year’s ESC Congress? Will you stay entirely online or both?

Prof. Achenbach: We are currently working on it. We are designing ESC 2021 as an online event. The online format will be different from an on-site event. There will be shorter sessions, interactive sessions, live sessions transmitted from several places at the same time. We are designing an online congress. Maybe we will add an on-site component to it if developments continue with vaccination and so on, but the primary event and programming is planned to be delivered online. We are currently holding planning meetings. We have a group of around seventy doctors planning the programming, which is the system we use at ESC. It is usually in December when we plan the sessions. So that is happening around now. The entire structure has been changed so it is optimized for online delivery. 

Prof. Qian:By being online, can the ESC Congress be longer or expanded to include more content with multiple channels available and less cost?

Prof. Achenbach: The duration of the Congress won’t be longer. Physicians have to return to their work at hospitals and clinics. The content will be available longer of course. Will there be more sessions or less? We are worried that if we add a lot more then it would overwhelm participants. It is like when you go shopping and there is one type of jeans you can buy. You buy it and you are happy. If the store has ten styles of jeans, you consider for a long time and buy one but end up unhappy thinking the other jeans may have been better. More choice does not always translate into greater happiness. We have to find a good balance, and we will not be adding a lot more sessions than we usually have at the on-site meeting. However, timings will be adapted. We will have sessions in the middle of the night in Europe so they can be consumed during the daytime live in other parts of the world. In that way we will certainly expand. 

Prof. Qian: We hope we can attend the next ESC Congress to share the culture of Europe, the education and the top level experience. 

Prof. Achenbach: We will welcome you to an ESC Congress at some stage in the future, and I very much look forward to it. 

Dr. Gao : I wonder if I could ask all the Professors, if once the pandemic is over, they think the online meeting will disappear or become the replacement, or will the on-site meeting become our top priority?

Prof. Achenbach: If I’m going first, on-site meetings will remain. At least the large ones, because humans want to get together. It is in our genes. We want to meet. We want to exchange. We want to have fun together and think together. There is something about meeting each other that you can not replace. Even smell. We all know there are olfactory signals that make us feel comfortable in a community. This is what we want, and this is why these meetings will not go away. They may change. They might become smaller. But I am convinced they will not go away. Maybe I am completely wrong. We will see. Maybe I am a dinosaur and become extinct. But I am pretty convinced they will continue. 

Prof. Zhou: Human beings always try not be robots or machines. I think we can conquer COVID-19 in China and the rest of the world with the range of vaccines available across the globe being applied to sufficient people to end the pandemic status of the virus. Where will the ESC Congress be held in two years time?

Prof. Achenbach: We are still negotiating destinations for 2022 because we had some cancellations, so it is not decided yet. But I am sure it will be a very attractive destination in Europe. 

Prof. Zhou: Across our hospitals in China, we see around 20000 PCI cases per year, and 30000 coronary angiography cases. Many of our interventional physicians are like machines working around the clock and have little opportunity to talk about COVID-19 management in our field, so hearing about your experience in Germany is really helpful. China’s government has been very determined in controlling the situation here since the initial Wuhan outbreak. Now, only a few Chinese cities are experiencing cases, and the situation is improving rapidly. In Europe, I think a vaccine will be the next positive step for their situation. 

Prof. Achenbach:We are getting ready for vaccinations in Europe, but it will take a while to get the necessary proportion (20-30%) of the population vaccinated. It is a logistical challenge. 

Prof. Qian: Regarding future Chinese conferences, we would expect COVID-19 to still be present next year here and in parts of the world so it depends. Large conferences may not be allowed, and I think the following year may be more practical. But I agree with Professor Achenbach when he says we are human. We like to be together with our colleagues and friends, to talk and have a drink and dinner. On-site conferences are very attractive but for the future. They may change a lot because online conferences are also cheap and can be very efficient. But the larger and more famous conferences will still be held on-site in the future. 

Prof. Achenbach: I would like to wish you all the very best as this difficult year comes to an end. We can see that China has done a fantastic job facing this challenge very early. Other countries can learn from you, and we are grateful for that. Let’s hope that next year, and for many years after that, we can do better. We can’t forget that cardiovascular disease is much more dangerous than COVID-19 and will be with us for a very long time. We have to fight together to reduce the burden of cardiovascular disease. Thank you very much.