1. The worldwide pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has placed an enormous strain on the health care systems of the nations where it has spread widely, with specific implications on practice in the catheterization laboratory. These implications include how we might modify practice for standard cardiac patients, those who are suspected to have COVID-19, and those with COVID-19.
2. At this time, to preserve hospital bed capacity, it would seem reasonable to avoid elective procedures on patients with significant comorbidities or in whom the expected length of stay is >1 to 2 days (or anticipated to require the intensive care unit). Examples of procedures to defer include:
   • Percutaneous coronary intervention for stable ischemic heart disease,
   • Endovascular intervention for iliofemoral disease in patients with claudication, and
   • Patent foramen ovale closure.
3. Case decisions should be individualized, taking into account the risk for COVID-19 exposure versus the risk for delay in diagnosis or therapy.
4. In a patient with known COVID-19 and ST-segment elevation myocardial infarction (STEMI), the balance of staff exposure and patient benefit will need to be weighed carefully.
5. Fibrinolysis can be considered an option for a relatively stable patient with STEMI with active COVID-19. In patients with active COVID-19 in whom primary percutaneous coronary intervention is to be performed, appropriate personal protective equipment should be worn, including gown, gloves, goggles (or shields), and an N95 mask, especially given the limited ability to take a history from such patients as well as the potential for clinical deterioration in those with STEMI.
6. For most patients with non-STEMI (NSTEMI) and suspected COVID-19, timing should allow for diagnostic testing for COVID-19 prior to cardiac catheterization and for a more informed decision regarding infection control. Efforts should be made to try to differentiate between type 2 myocardial infarctions and “primary” acute coronary syndromes, with consideration of deferral of invasive management in the former, especially if the patient is hemodynamically stable.
7. Patients with COVID-19 or suspected COVID-19 requiring intubation should be intubated prior to arrival to the catheterization laboratory. Furthermore, the threshold to consider intubation in a patient with borderline respiratory status may need to be lowered to avoid emergent intubation in the catheterization laboratory.
8. Consideration should be given to laboratory downsizing case volumes (e.g., deferral of elective cases) and/or shift-based allocation of staff members and physicians needed to operate the laboratory in anticipation of likely disruptions to staffing.
9. The vast majority of catheterization laboratories have either normal or positive ventilation systems and are not designed for infection isolation. Given the need for terminal cleaning following procedures on patients with suspected or known COVID-19, these cases should be done at the end of the working day if possible. For known COVID-19-positive patients, restriction of cases to a dedicated laboratory may be of value.
10. Finally, as the pandemic progresses, we will need to create avenues for reporting and collation of data and then methods for rapidly dispersing that information in order to better care for our patients and to protect health care workers in the cath lab.

Clinical Topics: Acute Coronary Syndromes, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Prevention, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Interventions and ACS, Interventions and Structural Heart Disease, Interventions and Vascular Medicine

Keywords: Acute Coronary Syndrome, Cardiac Catheterization, Cardiology Interventions, COVID-19, Endovascular Procedures, Fibrinolysis, Foramen Ovale, Patent, Hospital Bed Capacity, Intermittent Claudication, Length of Stay, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Personal Protective Equipment, Primary Prevention, Respiration, Artificial, SARS Virus, severe acute respiratory syndrome coronavirus 2, Elective Surgical Procedures

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