Reintroducing Echocardiography During COVID-19: Guidance From ASE

echocardiography, ECG
With the initial surge of COVID-19 pandemic easing across the United States, safe reintroduction of cardiovascular diagnostic imaging will be crucial.

With the initial surge of the coronavirus disease 2019 (COVID-19) pandemic easing across the United States, safe reintroduction of cardiovascular diagnostic imaging, including transthoracic and transesophageal echocardiography (TTE and TEE, respectively), will be crucial, according to recommendations issued by the American Society of Echocardiography and published in the Journal of the American Society of Echocardiography. Toward that end, institutions should continue to focus on viral transmission risk minimization, with personal protective equipment (PPE) used based on factors such as local epidemiological data and resource availability.

The COVID-19 pandemic has altered much of the healthcare landscape, and resumption of nonurgent services, including outpatient echocardiography, should follow a gradual phasic reopening plan that relies on local and institutional statistics and variables. Rescheduling of cases deferred because of the pandemic should be prioritized according to their urgency, and should be tiered accordingly. Disinfection and enhanced protection protocols should be maintained to ensure social distancing. All patients should be screened for COVID-19 symptoms prior to their appointments, at multiple times, and should wear facemasks for the duration of the interaction.

Although scheduling priorities are similar for TTE and TEE in terms of clinical urgency, the latter requires additional precautions and PPE, as it is considered high-risk for aerosol generation. Specialized designated rooms are optimal to conduct TTE, and sufficient time should be allowed between procedures to clear the air of potential pathogens. Droplet or airborne precautions should be taken when performing these studies.

Staff anxiety, likely already exacerbated during the pandemic, can be managed with efficient and clear communication of and adherence to safety guidelines. Stress reduction resources should be made available to healthcare workers whenever available.

Although comprehensive 2-dimension echocardiography is still recommended for most patients, more focused exams may be used in situations in which completeness and practitioner safety need to be balanced. For patients in whom stress echocardiography is indicated, pharmacologic inducement should be used in place of exercise, in an effort to lower aerosol generation.

Regular disinfection of common areas and high-traffic surfaces (eg, door handles) should be standard. The use of PPE should strike a balance between adequate protection of providers and resource availability, taking into account local trends to dictate intensification or relaxation of these protocols, with a focus on conservation. PPE should be categorized as standard, droplet- or airborne-adapted, with increased level of protection adapted to the situation. Adequate equipment cleansing and diligent hand washing should continue in all cases to minimize viral transmission.

COVID-19 diagnostic testing should be conducted in symptomatic patients or in those suspected of having been in contact with confirmed cases. Providers should be cognizant of the possibility of false negative results. Nonurgent imaging studies should be deferred for patients who test positive for COVID-19. In these patients, rescheduling should be conducted in consultation with infectious disease experts. In patients positive for COVID-19 but who cannot wait for a TTE or TEE, special precautions should be taken as noted above.

In pediatric patients needing TTE or TEE imaging, special consideration should be given to intrateam communication, focused protocols, higher level PPE, and limitations regarding accompanying adults. When sedation is required, conscious sedation should be used instead of inhaled anesthetics to reduce aerosol generation. In addition, droplet or airborne precautions should be followed, and diagnostic testing with deferral for patients who test positive for COVID-19 should be instituted whenever possible.

“Monitoring of patients and providers for COVID-19 resurgence will be key in determining the response level of the institution and protocols for diagnostic echocardiograms,” noted the authors.

Funding and Conflicts of Interest Disclosures

The following authors reported relationships with one or more commercial interests: Theodore P Abraham, MD, FASE, holds equity in Perceptive Navigation. Vera H Rigolin, MD, FASE owns stock in Pfizer, Astra Zeneca, Bristol Myers Squibb, Merck, Portal Pharmaceuticals, and ICU Medical.


Hung J, Abraham TP, Cohen MS, et al. ASE statement on the reintroduction of echocardiography services during the COVID-19 pandemic. J Am Soc Echocardiogr. May 2020. doi:10.1016/j.echo.2020.05.019