This statement by the American Society of Echocardiography (ASE) provides guidance on how to protect patients and providers during echocardiographic exams amidst the COVID-19 pandemic. It outlines different triaging and decision pathways across three distinct categories. The following are key points to remember:

1. Whom to image:

• Appropriate use criteria should be applied first.
• Involve referring physicians in the triaging process.
• Image only if it will yield clinically important information in the short term.
• Establish the COVID status of a patient, as this will allow for the appropriate use or conservation of personal protective equipment (PPE).
• Restrict use of imaging modalities with greater risk of aerosolization: 1) For transesophageal echocardiography (TEE): alternative imaging modalities (such as off-axis transthoracic echocardiography (TTE), ultrasound-enhancing agent with TTE, computed tomography, and magnetic resonance imaging) should be explored first for patients with known COVID-19. 2) For treadmill/stress echocardiography: defer or change to a pharmacologic agent.

2. Where to image:

• Take advantage of portability of echocardiography and ability to perform studies at bedside, and in isolation for suspected or confirmed COVID-19 patients.
• For outpatients, screening for COVID-19 prior to testing should be done according to local protocols. Separate rooms and/or machines can be used for patients with suspected or confirmed infection.

3. How to image:

• Point-of-care cardiac ultrasound (POCUS) or ultrasound-assisted physical examination (UAPE) can be performed at the bedside by those already providing care for the patient. Storing these images with subsequent review by an echocardiographer can serve as an important screening tool to decide whether formal echocardiography is needed.
• Echocardiographic studies should be planned in advance based on the indication and other clinical and imaging data available to allow for obtaining only problem-focused, limited exams.
• If ultrasound-enhancing agents are needed, this should be considered prior to the exam as well.
• Scan times should be kept to a minimum by excluding student or junior sonographers. For TEE, cases should be limited to essential personnel and may preclude junior cardiology fellows.
• The type of PPE used in each case will be dictated by the local institution, based on its own policies and available resources. However, airborne precautions (N95 respirator masks, or powered air-purifying respirator systems) are required during TEE for suspected and confirmed COVID cases.
• All machines and probes should be thoroughly cleaned with standard viricidal disinfectants, ideally in the patient’s room and again in the hallway.
• At-risk personnel (>60 years old, pregnant, immunocompromised, chronic disease/cardiopulmonary conditions) should be identified and appropriately re-assigned.
• Reading rooms should enforce methods to reduce transmission by encouraging remote reading and echo consultations.

Clinical Topics: COVID-19 Hub, Noninvasive Imaging, Prevention, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Coronavirus, COVID-19, Diagnostic Imaging, Disinfectants, Echocardiography, Echocardiography, Stress, Echocardiography, Transesophageal, Magnetic Resonance Imaging, Personal Protective Equipment, Pregnancy, Respiratory Protective Devices, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Tomography, X-Ray Computed, Ultrasonography

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