The following are key perspectives from this Viewpoint about priorities for catheterization laboratories (cath labs) in the COVID-19 tsunami:

1. The COVID-19 tsunami has reached the cath labs and will affect everyone in it, especially those labs (the majority) with direct access for patients for primary percutaneous coronary intervention.
2. It is essential and critical to be prepared in advance. Awaiting the first COVID-19 patient’s arrival and then improvising corresponds to waiting for a disaster. Today, the first priority is the safety of the team—a team in quarantine means the inability to save many more patients.
3. While time to revascularization remains a priority, patient outcome does not change much if extra time is taken to secure the workforce first. The room and the team need to be well prepared to receive positive or suspected COVID-19 patients by wearing personal protective equipment including gloves, gowns, goggles, shields, glasses, and FFp3 or N95 masks.
4. The first priority is to prepare each team beforehand. Cath lab directors have to:
   • Obtain (and look at!) adequate protective equipment;
   • Train (and train again and again) the teams;
   • Define a command structure, learning from disaster medicine such as war, as we are actually at war!
5. At the same time, patients should be reassured about the safety of hospitals with areas for COVID-19 patients separated from the others. The message should be reformulated: ‘Business as usual. If you have chest pain, call an ambulance. The risk of mortality for myocardial infarction outweighs that of COVID-19 infection.’
6. Ideally, a dedicated cath lab should be located in a COVID-19 area of the hospital, but this may not always be possible. In the latter case, a ‘temporary’ COVID-19 lab and procedure with a protected team needs to be set up for each patient.
7. For non–ST-segment elevation myocardial infarction (NSTEMI) patients, timing should allow diagnostic testing for COVID-19 infection (by either positive swab samples or lung computed tomography scan) prior to cardiac catheterization. Positive cases should follow the same protocol as STEMI patients, if they cannot be managed by optimal medical therapy.
8. Rapid discharge of these NSTEMI patients after revascularization is recommended to maximize bed availability and to reduce exposure within the hospital. Whenever possible, these patients should be followed-up at home via telemedicine.
9. Transportation of suspected or positive COVID-19 patients from the cath lab to the appropriate area of the hospital (either known COVID-19 or just suspect) should occur with protected staff following predetermined pathways and safe corridors. At the end of each procedure, the necessary cleaning time for the cath lab should be allowed.
10. Finally, there is the need for strong alliances, perfect networking, and much training. However, inevitably, something will go wrong, as no plan will work perfectly under a tsunami. However, one should aim, as a minimum, to reduce the disaster.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Computed Tomography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Cardiac Catheterization, Chest Pain, COVID-19, Coronavirus, Eye Protective Devices, Masks, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Primary Prevention, Quarantine, severe acute respiratory syndrome coronavirus 2, Telemedicine, Tomography, X-Ray Computed, Tsunamis

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