Specific Considerations for Pediatric, Fetal, and Congenital Heart Disease
Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak: Council on Pediatric and Congenital Heart Disease
Supplement to the Statement of the American Society of Echocardiography
Endorsed by the Society of Pediatric Echocardiography and the Fetal Heart Society© 2020 American Society of Echocardiography
Piers C.A. Barker, MD, FASE (Chair), Mark B. Lewin, MD, FASE, Mary T. Donofrio, MD,
FASE, Carolyn A. Altman, MD, FASE, Gregory J. Ensing, MD, FASE, Bhawna Arya, MD,
FASE, Madhav Swaminathan, MD, FASE, Durham, North Carolina; Seattle, Washington;
Washington, District of Columbia; Houston, Texas; Ann Arbor, Michigan.

From Duke University, Durham, North Carolina (P.B. and M.S.); University ofWashington/Seattle Children’s Hospital, Seattle, Washington (M.L. and B.A.); Children’s
National Hospital, Washington, District of Columbia (M.D.); Baylor College of Medicine/Texas
Children’s Hospital, Houston, Texas (C.A.); University of Michigan/C.S. Mott Children’s
Hospital, Ann Arbor, Michigan (G.E.).
The authors reported no actual or potential conflicts of interest in relation to this document.

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Notice and Disclaimer: This statement reflects recommendations based on expert opinion,
national guidelines, and available evidence. Our knowledge with regard to COVID-19 continues
to evolve, as do our institutional protocols for dealing with invasive and non-invasive proceduresand practice of personal protective equipment. Readers are urged to follow national guidelines
and their institutional recommendations regarding best practices to protect their patients andthemselves. These reports are made available by ASE as a courtesy reference source for its
members. The reports contain recommendations only and should not be used as the sole basis tomake medical practice decisions or for disciplinary action against any employee. The statements
and recommendations contained in these reports are primarily based on the opinions of experts,
rather than on scientifically-verified data. ASE makes no express or implied warranties regarding
the completeness or accuracy of the information in these reports, including the warranty ofmerchantability or fitness for a particular purpose. In no event shall ASE be liable to you, yourpatients, or any other third parties for any decision made or action taken by you or such otherparties in reliance on this information. Nor does your use of this information constitute theoffering of medical advice by ASE or create any physician-patient relationship between ASE andyour patients or anyone else.

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Background
The American Society of Echocardiography has recently released a statement on the “Protectionof Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus
Outbreak” which will be continually updated as more data become available.1 The pediatric andcongenital heart disease (PCHD) population adds a confounding variable to this pandemic,
which this supplement to the main statement1 means to address. Readers are recommended toreview the main statement;1 this supplement will discuss how the PCHD population is different
from the adult population, including transmission risk and indications for echocardiography;
variations in protocols; and recommendations for fetal echocardiography and transesophageal
echocardiography (TEE) for the PCHD population.
Although children as an entire group appear to be at lower risk for severe disease compared toadults, certain ages are more susceptible to severe disease than others (particularly infants andpre-school aged children, and possibly premature infants).2 The overall lower prevalence ofsevere disease paradoxically means that a large number of infected children may be
asymptomatic or minimally symptomatic.2,3 When combined with the high viral loads present in
nasopharyngeal and fecal secretions,4,5 frequency of other upper respiratory tract viral coinfections,3 necessity of adults accompanying children to medical care, and limited capabilities toavoid droplet expression in infants and toddlers, echocardiographic scanning of children may
create an increased risk of staff and community exposure. Consequently, PCHD
echocardiography providers will be exposed to SARS-CoV-2, perhaps often unknowingly,
requiring adjustments in practice to provide expert care and limit further community
transmission.
Indications for the use of echocardiography in the PCHD population also differ from the adult
population.6 For PCHD patients, echocardiography will remain critical for the assessment ofchildren with suspected heart disease, management of children and young adults with acquiredand congenital heart disease at different stages of repair, palliation or transplant, and children at
risk of functional heart disease (e.g. receiving chemotherapy) or cardiac complications from
respiratory infection. Fetal and transesophageal echocardiography represent important clinicalscenarios requiring variations in management. Pregnancies will continue and fetal heart diseaseremains critical to diagnosis and manage, albeit while reducing risk for infection of the mother orprovider. Avoidance of provider transmission to the premature infant population with lungdisease of different etiologies is similarly critical.

Whom to image?
Review of Indications
As a general principle, transthoracic echocardiograms (TTE), stress echocardiograms,
transesophageal echocardiograms (TEE), and fetal echocardiograms should only be performed ifthey are expected to provide clinical benefit. Decisions on whether or not an echocardiogram

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should be performed in a PCHD patient may be guided by the appropriate use criteria establishedby the ASE and other societies,7,8 with risk of SARS-CoV-2 infection highlighting the need to
avoid rarely appropriate exams. In addition, multiple societies (AIUM, ISUOG and AHA) haveestablished guidelines for indications for fetal echocardiography referral. A full discussion of
how to determine both who should be imaged as well as when imaging should be considered ispresented in the main statement,1 acknowledging that adjustments to these decisions should bemade by each individual institution.
Fetal echocardiographic evaluation presents different challenges; there is a finite gestational
period within which pregnancy decision-making and perinatal/neonatal management plans are
made. The AHA divides fetal echocardiography referrals into risk levels based on indication.9
Triage and scheduling of these patients in general can be determined based on an assessment oflevel of risk relating to the indication for referral as well as the fetal diagnosis. TEE carries aheightened risk of spread of SARS-CoV-2 since it can provoke aerosolization of a large amountof virus. Whether the intubated PCHD patient having a TEE exposes the care team to a greaterrisk with this modality compared to TTE remains unclear. Considerations for both fetal
echocardiography and PCHD TEE are discussed in greater detail in the Advanced Imaging
section below.

Where to image?
The increased possibility that children may be infected with no or minimal symptoms may limit
the utility of adult-focused screening measures. This may then necessitate adjustments to both
inpatient and outpatient procedures such as designating which studies should be performed as
portable studies, or designation of specific echo lab scan rooms or outpatient clinic sites. Given
the higher risk of asymptomatic transmission in children, some centers in endemic regions arealso choosing to test all new pediatric admissions for SARS-CoV-2.
For institutions where fetal imaging occurs within the cardiology clinic, consideration should begiven for pregnant women to be sequestered in a separate area from the pediatric patients, bothin the waiting room and echo lab. Unlike previous viral outbreaks (H1N1, SARS-CoV, MERSCoV) which were found to be associated with severe complications in pregnant women,
currently the limited information available suggests that pregnant women are not more
susceptible to SARS-CoV-2 infection or more prone to developing severe complications if
infected.10 Given the uncertainty and possibility of increased risk as more data become
available, the CDC cautions that it is always important for pregnant women to protect
themselves from illnesses, though the current recommendation is for them to follow the same
precautions as the general public to avoid infection. For fetal cardiology visits, a maximum of
one support person who undergoes the same screening process as the patients may accompany
the pregnant women to the visit; however to minimize exposure, the echocardiogram scanning
room should be limited to the pregnant woman alone and sonographer. Counseling of thefamily should be limited to the pregnant woman and one support person at most, though if

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possible having the support person be offsite and participate in the counseling session using
telemedicine may be beneficial. Telemedicine consultation without fetal echocardiogram should
be considered when the visit is limited to follow-up counseling of established fetal
cardiovascular disease. If the fetal echocardiogram can be performed and then read remotely(e.g. for known CHD, SSA/SSB antibody or arrhythmia follow-up), telemedicine should beconsidered for relaying findings and performing counseling. This may be particularly useful if
the fetal echocardiogram can be done in the Maternal-Fetal Medicine (MFM) office, wherevisits can be consolidated to include routine obstetrical care. Home fetal heart rate monitoringwith telemedicine consultation instead of intermittent fetal echocardiography can also be
considered in cases of fetal arrhythmia to minimize follow-up clinic visits.
How to image?
Protocols
Infants or children presenting with known or suspected congenital heart disease, cardiomyopathyor myocarditis may have intercurrent respiratory illnesses and thus may be under suspicion for
SARS-CoV-2 infection. This will require modification of PCHD imaging protocols away from“complete” studies and towards more focused exams. However, the breadth of congenital heartdisease, and the challenges of systolic and diastolic function assessment in the PCHD population
mean that unless the patient is in immediate need of assessment of only systolic function or
pericardial effusion, "traditional" TTE by cardiology (pediatric or ACHD) is preferred over pointof care ultrasound (POCUS) in the pediatric emergency center or intensive care unit. If a
POCUS exam is performed, images should be saved and archived in a manner that allows review
and remote interpretive assistance from experienced pediatric echocardiographers as well ascomparison of cardiac structure and function over time. Review of POCUS studies may also help
focus future imaging studies.
Additional recommendations for focusing exams, particularly in patients with suspected orconfirmed COVID-19, are presented in the main statement.1 These include the use of live feeds
and/or remote feedback to limit personnel in the patient room, and matching of sonographer skill
to study indication to maximize diagnostic accuracy while minimizing scan time. As for adultpatients, scans should be reviewed, and results recorded and communicated to the ordering teamas quickly as possible to facilitate care.
For fetal echocardiographic studies, a complete study should be performed for all new
consultations in order to minimize the need for repeat studies. Centers should have well-definedstudy protocols and checklists available as the study is being performed and as it is reviewed
prior to the pregnant woman leaving the exam room. For follow-up scans deemed necessary, afocused study based on a predetermined checklist provided by the fetal cardiologist may beutilized. Prolonged scanning should be avoided. Transvaginal fetal echocardiographic studies
should not be performed.

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Protection
Imaging of the pediatric patient with possible or confirmed COVID-19 differs from imaging of
the adult in several ways. Children may frequently be asymptomatic or minimally symptomatic,
which may unknowingly expose the provider to infection. Children are often unable tocooperate and follow instructions; cardiac anatomy may be highly variable and require longer
scan times to assess; and sedation may be necessary for even routine transthoracic studies. Thus
protection procedures require modification to those recommended for general adultechocardiography as presented in the main statement.1 These PCHD modifications are presented
below. Additional information regarding the role of learners, options for echocardiography
education in the absence of direct scanning, and important general considerations for reducing
transmission outside of the scan room are presented in the main statement.1
Personnel
As for the adult patient, imaging should be performed according to local standards for theprevention of virus spread, including use of Personal Protective Equipment (PPE). Meticulous
and frequent hand washing is crucial and applies to the sonographer, patient when possible, andto a single caregiver who is likely to contact patient and sonographer while helping to facilitate
the cooperation of an active child. A surgical face mask should be worn by symptomaticpatients, provided appropriate pediatric and adult-sized masks are available and institutional
resources allow this strategy for source control.11 In addition to the aerosolized transmission of
SARS-CoV-2, potential for fecal transmission has been reported.5,12 Diaper care should
therefore be avoided if possible during the exam, and if necessary performed with appropriate
virucidal hygiene.
The performance and interpretation of pediatric and fetal echocardiographic studies, especiallythose in suspected or confirmed COVID-19 cases, should be limited to essential personnel.
Potentially complicated exams should be directed to experienced sonographers who are most
likely to be able to perform an appropriately detailed, accurate, and expeditious exam without theneed for additional hands-on support. In many institutions, PCHD fellows provide crucial offhours scanning and interpretation, but their skill level should be matched to patient complexity
with availability of additional imager expertise when an expeditious exam cannot be obtained.
In addition to limiting the number of echocardiography practitioners involved in scanning,
consideration should be given to limiting the exposure of staff who may be particularly
susceptible to severe complications of COVID-19. Staff who are >60 years old, have chronic
conditions, are immunocompromised or are pregnant may wish to avoid contact with patientssuspected or confirmed to have COVID-19, depending on local procedures.
For intraoperative TEE, which is an essential contributor to the effective surgical treatment ofcongenital heart disease, strong consideration should be given to requesting that theanesthesiologist place the TEE probe immediately after airway intubation while using
appropriate aerosol precautions. Probe removal should be performed while under deep generalanesthesia while intubated, with the probe immediately cleaned and then placed in a transport

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container for disinfection. There should be at most one person to handle the probe and another tooperate the machine controls, along with another to administer anesthesia or sedation. Many
pediatric echocardiographers are capable of simultaneously manipulating the TEE probe andoperating the machine; this practice should be encouraged to reduce exposure of an additional
provider, presuming skill with this technique and that use of this technique will not increase total
scan time.
Equipment
Equipment care is critical in the prevention of SARS-CoV-2 transmission. Options to decrease
fomite transmission may include covering probes and machine consoles with disposable plastic
and foregoing the use of ECG stickers, or setting aside certain machines or probes for use on
patients with suspected or confirmed infection. Similarly, setting aside a separate machine forsole use in expected high-risk groups such as the neonatal intensive care unit is encouraged whenpossible. Equipment cleaning should be performed according to institutional and vendor
guidelines. Additional guidelines for the disinfection of ultrasound equipment are available
through the AIUM.13 Smaller, laptop-sized portable machines are more easily cleaned, but useof these machines should be balanced against potential tradeoffs in image quality andfunctionality.
Advanced Imaging:
Fetal Echocardiography
Fetal echocardiography and the care of pregnant women require a separate triaging system,
which can be divided into three subgroups (Table and Figure 1).
•

Fetal echocardiogram for low risk patients: if a detailed second trimester fetal anatomic
scan including adequate cardiac screening views can be confirmed by combined
experience of practitioners (fetal cardiologist with Maternal-Fetal Medicine
specialist/Obstetrician), no fetal echocardiographic evaluation is scheduled.

•

Fetal echocardiogram for moderate risk patients: delay fetal echocardiographyevaluation to a later date when SARS-CoV-2 risk is decreased or after 28 weeks
gestation (or earlier in specific situations, described in more detail below).

•

Fetal echocardiogram for high risk patients or urgent clinical indications: schedule andperform promptly (though consider alternatives such as lowest risk facility for imaging
and telemedicine for consultation to minimize risk).

This triage system requires close communication with the referring Obstetrical and MaternalFetal Medicine teams; noting that the recommended algorithms presented are not evidence-based
but do represent shared perceived best practices and can be modified by each institution to best
match local resources. Once it is decided that a Fetal Cardiology visit is needed, the timing of
the Fetal Cardiology visit is based on multiple factors: 1) the risk profile of the indication (seeTable); 2) the adequacy of the anatomy scan with cardiac views (determined by local

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collaborative experience of the referring doctor and fetal cardiologist, or if needed, direct reviewof the cardiac screen, or discussion with the referring doctor); 3) the gestational age of the fetus
which influences both pregnancy decision-making and need for additional testing (e.g.
amniocentesis, ultrasound, MRI, gestational age < 24 weeks) and delivery planning for fetal
CHD (gestational age ≥ 34 weeks). For those deferred to a later date, creation of a virtual“waiting list” should be considered for scheduling to assure that all patients at risk are evaluatedprior to delivery. Fetal cardiovascular diseases requiring transplacental therapy (e.g. fetal
tachyarrhythmia or autoimmune-mediated evolving congenital heart block) should be consideredurgent indications for echocardiography and consultation, and scheduling and evaluating thesepatients should follow the admitting institutions COVID-19 policies for urgent admissions.
Performance of fetal cardiac interventions (i.e. balloon aortic or pulmonary valvuloplasty, atrial
septal stenting) remains at the discretion of the institution, though given the current body ofevidence on risk-benefit ratio, delaying or not doing the procedure may be considered. The
timing and performance of fetal interventions for twin-twin transfusion syndrome (TTTS) are
beyond the scope of this document.
The possibility of prenatal or perinatal infection should be considered when neonates aretransferred to the neonatal or pediatric cardiac intensive care unit following delivery. There isinconclusive data regarding vertical transmission of SARS-CoV-2; however, if a pregnant
woman tests positive for the virus within 14 days of delivery, the newborn should be tested
and treated as positive, with use of appropriate PPE, until a negative result is confirmed.

Transesophageal Echocardiography
Transesophageal echocardiography carries a heightened risk of spread of SARS-CoV-2 since
aerosolization of virus may be provoked during the procedure. This is of particular concern if
the TEE is performed without concomitant endotracheal intubation, due to the coughing or
gagging that may accompany probe placement and manipulation. However, aerosolization andprovider exposure may be possible even with an endotracheal tube in place due to the
instrumentation and manipulation of the oropharynx that occurs with TEE probe placement.
TEEs therefore deserve special consideration in determining when and whether they should be
performed, and under what precautions. TEE should be considered an integral part of PCHD
perioperative care or care during PCHD cardiac catheter interventions. Outside of thesescenarios, TEE should be considered a high-risk procedure and the benefits of a TEE
examination weighed against the risk of exposure of healthcare personnel in a patient withsuspected or confirmed COVID-19 and the availability of PPE. TEEs should be postponed orcanceled if an alternative imaging modality (e.g. off axis TTE views, agitated saline contrast orother ultrasound enhancing agent with TTE) can provide the necessary information. Contrast
enhanced computed tomography (CT) and magnetic resonance imaging (MRI) may also be
considered as alternatives to TEE. The benefits of avoiding an aerosolizing procedure should bebalanced against the risk of transport, need to disinfect a different scan room, as well as the8©American Society of Echocardiography

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baseline risks in children of iodinated contrast and radiation with CT, and longer scan times for
MRI.
Given the unreliability of symptoms to predict COVID-19 status in children, use of astandardized algorithm for TEE procedures is recommended. An example is presented below
and in Figure 2. Modification and implementation of any TEE algorithm should be coordinatedwith all members of the perioperative team at each institution to best match resources andequipment. Ideally, as SARS-CoV-2 testing becomes more available at the hospital level withmore rapid resulting, all patients for whom TEE is planned (i.e. most surgical patients, and someinterventional cardiac catheterization patients) should have SARS-CoV-2 testing performed
during pre-op screening.
1. All pediatric patients for TEE are presumed positive unless they have had a negative
COVID-19 test within 48 to 72 hours. If documented negative COVID-19 testing,then TEE may proceed using standard precautions (gloves, mask, and eye
protection).
2. For pediatric patients without COVID-19 negative testing within 72 hours who are
intubated prior to arrival to the Cardiovascular Operating Room(CVOR)/interventional suite, the risk for aerosolization is considered low. Probe
placement may be performed by anesthesia to minimize personnel performing
oropharyngeal manipulation or by cardiology according to institutional standard
procedures and following standard precautions.
3. For asymptomatic patients without COVID-19 negative testing within 72 hours who
require intubation in the CVOR/interventional suite, anesthesia should intubate
donning appropriate PPE/Powered Air Purifying Respirators (PAPR). This should be
followed by a wait period (typically 20-30-minutes depending on local protocols andenvironmental factors) to permit complete air turnover in the room, during which no one
should enter. Strong consideration should be given to TEE probe placement byanesthesia immediately following airway stabilization while still under aerosol
precautions and prior to the air turnover period to minimize the risk of exposure ofadditional personnel. After the wait period, probe manipulation may be performed bycardiology according to institutional standard procedures and following standard
precautions.
4. For COVID-19 positive or symptomatic children without COVID-19 negative testing
within 72 hours, strict isolation is mandated. Strong consideration should be given toprobe placement by anesthesia to minimize risk of exposure associated withoropharyngeal manipulation and according to institutional standard procedures.
a. All personnel in the CVOR, interventional suite, or procedure room must wear
strict isolation gear at all times.
b. All personnel must have training in donning and doffing PPE/PAPR
c. Only essential personnel in CVOR to preserve PPE and mitigate exposure risk (1echo person only)

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Conclusion
The provision of echocardiographic services to the PCHD population remains crucial during this
SARS-CoV-2 outbreak. Differences between the adult and PCHD populations require
modifications to prior practices. These PCHD modifications are summarized in Figure 3.
Working together with our adult Cardiology, Anesthesia, Maternal-Fetal Medicine and Pediatriccolleagues, we can continue to provide high quality care while minimizing risk to ourselves, ourpatients and the public.

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Acknowledgements
This statement was prepared by Piers Barker, MD, Mark Lewin, MD, (representing the Societyof Pediatric Echocardiography), Mary Donofrio, MD (representing the Fetal Heart Society),
Carolyn Altman, MD, Gregory Ensing, MD, Bhawna Arya, MD, and Madhav Swaminathan,MD, and was approved by the American Society of Echocardiography executive committee on
April 2, 2020.
Protocols and procedures used in the preparation of this document courtesy of the authors,
Luciana Young, University of Washington/Seattle Children’s Hospital, Seattle, WA (for the TEE
algorithm) and many others through the COVID-19 Cardiology Listserv (Seattle Children’s
Hospital), Society of Pediatric Echocardiography discussion groups, and Fetal Heart Society
Forum members discussion group.

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References
1.

Kirkpatrick JN, Mitchell C, Taub C, Kort S, Hung J, Swaminathan M. ASE Statement on
Protection of Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak. J Am Soc Echocardiogr 2020; Article in Press. doi:
10.1016/j.echo.2020.04.001

2.

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Tong S. Epidemiological Characteristics of 2143
Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics. 2020; doi:
10.1542/peds.2020-0702

3.

Cruz A, Zeichner S. COVID-19 in Children: Initial Characterization of the PediatricDisease. Pediatrics. 2020; doi: 10.152/peds.2020-0834

4.

Wölfel R, Corman V, Guggemos W, Seilmaier M, Zange S, Mueller M, et al. Clinicalpresentation and virological assessment of hospitalized cases of coronavirus disease2019 in a travel-associated transmission cluster. MedRxiv 2020.03.05.20030502;
doi: 10.1101/2020.03.05.20030502

5.

Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infectionof SARS-CoV-2. Gastroenterology. (2020); doi: 10.1053/j.gastro.2020.02.055

6.

Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev
Cardiol. (2020); doi: 10.1038/s41569-020-0360-57.

Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R.
ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for
initial transthoracic echocardiography in outpatient pediatric cardiology: a report of theAmerican College of Cardiology Appropriate Use Criteria Task Force, American
Academy of Pediatrics, American Heart Association, American Society of
Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography andInterventions, Society of Cardiovascular Computed Tomography, Society for
Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am
Soc Echocardiogr. 2014;27(12):1247-1266.

8.

Sachdeva R, Valente AM, Armstrong AK, Cook SC, Han BK, Lopez L, et al.
ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use
Criteria for Multimodality Imaging During the Follow-Up Care of Patients With
Congenital Heart Disease: A Report of the American College of Cardiology Solution Set
Oversight Committee and Appropriate Use Criteria Task Force, American Heart
Association, American Society of Echocardiography, Heart Rhythm Society,
International Society for Adult Congenital Heart Disease, Society for Cardiovascular
Angiography and Interventions, Society of Cardiovascular Computed Tomography,
Society for Cardiovascular Magnetic Resonance, and Society of Pediatric
Echocardiography. J Am Coll Cardiol. 2020;75(6):657-703.

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9.

Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A,
et al. Diagnosis and treatment of fetal cardiac disease: a scientific statement from theAmerican Heart Association. Circulation. 2014;129(21):2183-2242.

10.

Poon LC, Yang H, Lee JCS, Copel JA, Leung TY, Zhang Y, et al. (2020) ISUOG Interim
Guidance on 2019 novel coronavirus infection during pregnancy and puerperium:
information for healthcare professionals. Ultrasound Obstet Gynecol. 2020 doi:
10.1002/uog.22013.

11.

CDC. Strategies for Optimizing the Supply of Facemasks.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html.
Published 2020. Accessed March 20, 2020.

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Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oraltransmission. Gastroenterology. (2020) doi: 10.1053/j.gastro.2020.02.054.

13.

AIUM. Guidelines for Cleaning and Preparing External- and Internal-Use UltrasoundTransducers Between Patients & Safe Handling and Use of Ultrasound Coupling Gel.
https://www.aium.org/officialStatements/57[aium.org]. Published 2020. Accessed March
28, 2020.

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Figure 1
Fetal Cardiology Clinic Scheduling Algorithm during COVID-19 Outbreak

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Figure 2
Suggested algorithm for performing TEE during COVID-19 Outbreak

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Figure 3

Summary of Recommendations for Policies/Procedures during COVID-19 Outbreak
•

•

•
•

•
•

•

•

16

Defer/Reschedule Options
o Identify and defer all elective exams
o Identify and perform only urgent/emergency examso Assess need for fetal echocardiogram and schedule using algorithm
Assess patient COVID-19 statuso Negativeo Suspectedo Unknown (for TEE, treat as suspected)
o Positive/confirmed
Provide for appropriate levels of patient and provider protection
TEEs are considered high risko Defer or use alternative imaging strategies if possibleo Perform SARS-CoV-2 testing at preoperative visit, if possibleo Proceed with TEE using precautions based on algorithm
Institutional PPE conservationo Defer non-urgent exams in suspected/confirmed cases
Limit exposure during exams
o Problem-focused, limited examinations guided by prior studies
o Match personnel skills to exam to minimize scan timeo Consider use of dedicated machine for suspected/confirmed cases or high-risk unitso Minimize both respiratory and fecal exposure during exam
Reading room methods to reduce transmissiono Facilitate remote report generation and echo consultationo Frequent disinfection of computer keyboard, mouse, surfaces, chairs, doorknobs
o Discourage congregating in the echo lab reading room
Identify and appropriately reassign special at-risk personnel (>60 years, chronic illness,
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Table: Fetal Cardiology Clinic Scheduling Structure during COVID-19 Outbreak
Category

Definition

ActionExamplesLow risk•••

Cancel or do notschedule

•
•
•
•
•
•

In vitro fertilization
Gestational Diabetes
Family history of CHD (excl. exceptions noted below)
Medication exposure
Single umbilical artery
Dichorionic twins (without additional concerns)•

Re-schedule orschedule after
COVID-19 risk isdecreased or GA >28 weeks (consider
creating a virtual“waiting list” totrack patients)•

Schedule next
available••

2nd opinion for CHD already identified; may schedule,
consider telemedicine review of images and counseling
Fetal anatomy scan cannot confirm normal cardiac
structures; may schedule but consider telemedicine
review of images and counseling if needed
Pre-gestational diabetes with HgbA1C >8, increased
NT >3.5, or CHD with increased recurrence in 1st
degree relative (e.g. left sided obstructive lesion,
heterotaxy, maternal AVSD)
Suspected CHD (any GA)
Known CHD at risk for compromise or rapid
progression
Final visit for delivery planning for known CHD or 2 nd
opinion for CHD
Genetic/extracardiac anomaly with need to assess heart
Fetal arrhythmia (excluding isolated premature atrial
contractions), new and follow-up as indicated
SSA/SSB positive mother; new visit (provide fetal
heart rate home monitor if available; follow-up at GAof 20 and 26 weeks)
Fetal anatomy scan does not confirm normal cardiac
structures
New monochorionic-diamniotic twin pregnancy,
particularly with concern for twin-twin transfusion
syndrome
Pre-gestational diabetes with HgbA1C >8, increased
NT >3.5, or CHD with increased recurrence in 1st
degree relative (e.g. left sided obstructive lesion,
heterotaxy, maternal AVSD)
Maternal anxiety not ameliorated with telemedicine
consultation
Review of cardiac screening exams or fetal
echocardiograms done offsite
2nd opinion for CHD already identified with complete
fetal echocardiogram available for review
Interval follow-up counseling for known CHD until >34 weeksCounseling sessions with maternal family/support off
site•Moderate risk•••

High risk•

Low risk referral indication
Fetal anatomy scan: Normal
cardiac screening exam(verified by combined
experience of practitioners,
or if needed by discussion
w/ MFM or image review )Moderate/high risk referralindications when GA ≥ 24
weeks
Confirmed CHD when GA <34 weeks

Urgent clinical indication
Moderate/high risk referralindication when GA < 24weeks
Confirmed CHD when GA >34 weeks

•

•
•

•
•
•
•
•
•
•

•
•
•

Telemedicine•

Remote image review
Ongoing f/u care incollaboration with MFM
Counseling•

Perform as needed

•
•
•
•

17

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Resources
1. ASE COVID-19 resource page. https://www.asecho.org/covid-19-resources/
2. Connect@ASE COVID-19 discussion page. https://connect.asecho.org/groups/534Coronavirus-(COVID-19)
3. American Institute for Ultrasound in Medicine (AIUM) guidelines for equipment
disinfection. https://www.aium.org/officialStatements/57 [aium.org]
4. Centers for Disease Control COVID-19 resource page.
https://www.cdc.gov/coronavirus/2019-nCoV/index.html
5. Centers for Disease Control recommendations for infection prevention and control.
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecommendations.html
6. Centers for Disease Control visual guide for using personal protective equipment.
https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf
7. ISUOG Safety Committee Position Statement: Safe performance of obstetric andgynecological scans and equipment cleaning in the context of COVID-19.
https://www.isuog.org/resource/isuog-safety-committee-position-statement-safeperformance-of-obstetric-and-gynecological-scans-and-equipment-cleaning-in-thecontext-of-covid-19.html
8. The Society for Maternal Fetal Medicine COVID-19 Ultrasound Practice Suggestions.
https://s3.amazonaws.com/cdn.smfm.org/media/2272/Ultrasound_Covid19_Suggestions_(final)_03-24-20_(2)_PDF.pdf

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