Specific Considerations for the Protection of Patients and Echocardiography
Service Providers When Performing Perioperative or Periprocedural
Transesophageal Echocardiography During the 2019 Novel Coronavirus
Outbreak: Council on Perioperative Echocardiography Supplement to theStatement of the American Society of Echocardiography
Endorsed by the Society of Cardiovascular Anesthesiologists© 2020 American Society of Echocardiography
Alina Nicoara, MD, FASE (Chair), Yasdet Maldonado, MD, MMM, Smadar Kort, MD, FASE,
Madhav Swaminathan, MD, FASE, G. Burkhard Mackensen, MD, PhD, FASE, Durham, North
Carolina; Cleveland, Ohio; Stony Brook, New York; Seattle, Washington
From Duke University, Durham, North Carolina (A.N. and M.S.); Cleveland Clinic, Cleveland,
Ohio (Y.M.); Stony Brook Heart Institute, Stony Brook, New York (S.K.); University ofWashington, Seattle, Washington (G.B.M.).
The authors reported no actual or potential conflicts of interest in relation to this document.

1©American Society of Echocardiography

ASEcho.org

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.

2©American Society of Echocardiography

ASEcho.org

BackgroundProtecting healthcare workers and preventing transmission of SARS-CoV-2 should be a toppriority during the ongoing COVID-19 pandemic. Transesophageal echocardiography (TEE)examinations carry a heightened risk of SARS-CoV-2 spread in non-intubated patients due topossible direct droplet transmission and/or viral aerosolization and inhalation during
insertion/removal of the probe and/or coughing. Although conducting a TEE in an alreadyintubated patient may reduce the risk of viral aerosolization, viral transmission may still occur
through direct contact with the patient’s secretions, resulting in contaminated hands andsurfaces. These infection risks apply not only to echocardiographers, but also to other patientsand personnel in the vicinity, as a result of cross-contamination whenever there may have been
improper handling or cleaning of the equipment.
The performance of TEE examinations, therefore, deserves special consideration in determining
appropriate use and special precautions. This statement reflects recommendations based on
expert opinion, national guidelines, and available evidence specifically as they pertain to
performing safe perioperative TEE. This document will not address specific recommendations
during point-of-care surface ultrasound (lung, heart, abdomen, vascular), nor will it address
criteria used in the decision making regarding postponing elective procedures or proceeding withcardiac surgical procedures deemed urgent or emergent.
Whom to image?
Practice guidelines for the use of perioperative TEE were developed by the American Society ofAnesthesiologists (ASE) and the Society of Cardiovascular Anesthesiologists1, 2. As indicated in
the main statement of the ASE on protection during COVID-193, TEE examinations should bepostponed or canceled if they are unlikely to change clinical care, or if an alternative imaging
modality (e.g. off axis transthoracic echocardiography (TTE) views, ultrasound enhancing agent
with TTE) can provide the necessary information. While non-essential TEE examinations
should be either deferred or postponed, patients under investigation or confirmed with COVID19 may still require TEEs in several clinical situations including (1) urgent or emergent cardiac
surgery, (2) patients with cardiac co-morbidities undergoing emergent non-cardiac surgery, or(3) hemodynamic instability due to undifferentiated shock in the perioperative period.
Deployment of alternative imaging modalities may not always be possible in the perioperative
patient population undergoing cardiac surgery and special consideration should be given to
triaging these patients on a case-to-case basis. Additionally, TEE provides invaluable dynamic
information, paramount to performing a successful procedure in certain clinical situations.
Surgical procedures in which the benefit of performing a TEE exam may outweigh the risk ofcontamination or cross-contamination include but are not limited to the following:(a) Infective endocarditis with valvular and perivalvular involvement(b) Stanford type A aortic dissection, especially in the presence of associated complications(e.g., aortic insufficiency, aortic root involvement, pericardial effusion).
(c) Initiation of temporary or durable mechanical circulatory support

3©American Society of Echocardiography

ASEcho.org

(d) Myocardial infarction with mechanical complications (e.g., ventricular septal defect, left
ventricular wall rupture, papillary muscle rupture).
(e) Prosthetic valve assessment
There are surgical procedures in which the use of TEE can be supplanted by observing
invasively derived hemodynamic data, other imaging modalities (e.g., fluoroscopy, epicardial
ultrasound imaging), or direct visualization of the heart in the surgical field, such as coronary
artery bypass graft, or endovascular stenting for Stanford type B aortic dissection with peripheral
malperfusion. In these procedures, TEE can be considered in situations of severe hemodynamic
instability or procedural complications, which require immediate diagnosis and in which the TEE
findings would highly impact patient outcome (Figure 1)
Where to image?
Perioperative TEE examinations will likely be performed in operating rooms, structural heart
and catheterization laboratory rooms, or in the intensive care units. Patients with suspected orconfirmed COVID-19 infections should undergo surgical or interventional procedures in
dedicated COVID-19 operating rooms, or may be admitted in intensive care unit rooms. Specificconsiderations should be given to entering and especially exiting these spaces in order to limit
virus transmission.
How to image?
Protocols
TEE examinations performed in patients with suspected or confirmed COVID-19 should follow
an abbreviated but adequate pathology-directed protocol to limit personnel exposure time. Thisfocused exam approach should also be extensive enough for detecting and adequately evaluating
any significant unexpected pathology. Limiting factors in performing a comprehensive TEE
exam may be related to the patient’s clinical condition and the nature of the surgical procedure,
especially in patients undergoing urgent or emergent cardiac surgery. It is important to recordand store the acquired imaging data and cine loops so that they are available for review by otherclinicians. Findings should be communicated and reported in a timely manner, as per routine
practice.
Protection
Personnel
The levels and categories of personal protection equipment (PPE) are detailed in the mainstatement of the ASE on protection during COVID-193. While the type of PPE may depend on
institutional policies and available resources, it is generally accepted that performing TEEs insuspected or confirmed cases of COVID-19 warrants the use of airborne precautions, irrespectiveof the intubation status of the patient. All personnel should be educated in appropriate utility of
PPE as per institutional policies. Whenever possible, trained observers or the use of a “buddy
system” should ensure appropriate donning and doffing of the PPE. The most experienced

4©American Society of Echocardiography

ASEcho.org

echocardiographer should perform the examination, including probe insertion/removal. Althoughairborne precautions should be followed in all high risk patients (patients under investigation orconfirmed COVID positive patients), droplet precautions are recommended for TEEs in all nonCOVID patients4, 5.
Equipment
Proper handling and cleaning of the equipment is critical in prevention of virus transmission toother healthcare providers and other patients. The exact steps to be followed for disinfection of
the TEE probe and equipment will depend on local institutional protocols that should be guided
by infectious disease experts and resource availability. Plastic covers for the ultrasound machine,
its touchable parts (knobs, screen) and transducer ports are commercially available and should beconsidered in order to reduce bioburden on these “high touch” surfaces with hard-to-clean
grooves, slots or crevases (Figure 2). In order to avoid contamination of surfaces, one person
can be designated to probe manipulation and another one to adjusting instrument settings forimage optimization and data acquisition, although this approach has to be balanced with PPE
availability. As noted in the ASE main document3, removal of any non-essential accessory
equipment from the ultrasound machine (cart) such as additional alternate transducers, ECG
cables, ECG stickers, paperwork, gel (and any other items) will facilitate thorough cleaning andminimize risk for cross contamintation.
A practical approach is suggested in the Table. Following a TEE examination, all exposed
equipment should be wiped down with the hospital-approved and vendor-recommended
disinfection product in the procedure or intensive care room, and in the induction room oranteroom. The TEE probes should also be thoroughly wiped (including handle, cable, andconnector), placed in closed containers and transported in those containers to the cleaning
facility. The equipment surfaces should stay wet with the disinfection solution for the minimum
recommended “wet time” provided on the product label.
Role of learners
The educational benefit for trainees from performing TEEs in the perioperative period in patientswith suspected or confirmed COVID-19 should be weighed against the potential for prolonging
the examination time, the risk for contamination and cross-contamination and the additional
utilization of PPE. One approach would be to have trainees involved in interpreting and reporting
but not in performing these examinations. As institutional practices may vary, if trainees inadvanced fellowship programs are involved in performing this examinations, they should beknowledgeable and trained in the institutional protocols to reduce infection transmission. This
group does not recommend the involvement of medical students and residents in performing
perioperative TEEs in suspected or confirmed COVID-19 patients.

5©American Society of Echocardiography

ASEcho.org

Conclusion
The performance of transesophageal echocardiography carries a heightened risk of transmissionof SARS-CoV-2. This risk may be greater in non-intubated patients. TEE should be avoided inthese patients and alternative imaging modalities considered. TEE should be performed inintubated patients only in those perioperative situations in which the benefits outweigh the risks.
Careful consideration and practice of the recommendations above may help reduce the risk oftransmission and cross contamination.
Figure 1. Suggested algorithm for determining indication for intraoperative transesophageal
echocardiography (TEE)
Abbreviations: LV, left ventricle; RV, right ventricle; PPE, personal protection equipment; TTE,transthoracic echocardiography
Figure 2. Ultrasound system with transesophageal echocardiography capabilities is shown with aplastic cover. The screen, touchable parts and the transducer ports are covered by the disposable
plastic cover.
References:
1. Practice guidelines for perioperative transesophageal echocardiography. A report by theAmerican Society of Anesthesiologists and the Society of Cardiovascular
Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology
1996;84:986-1006.
2. Practice guidelines for perioperative transesophageal echocardiography. An updated
report by the American Society of Anesthesiologists and the Society of Cardiovascular
Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology
2010;112:1084-96.
3. 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 DOI: 10.1016/j.echo.2020.04.001
4. Bowdle A, Munoz-Price LS. Preventing Infection of Patients and Healthcare Workers
Should Be the New Normal in the Era of Novel Coronavirus Epidemics. Anesthesiology
2020 Mar 25. doi: 10.1097/ALN.0000000000003295.
5. He H, Zhao S, Han L, Wang Q, Xia H, Huang X, et al. Anesthetic Management ofPatients
6. Undergoing Aortic Dissection Repair With Suspected Severe Acute Respiratory
Syndrome Coronavirus-2 Infection. J Cardiothorac Vasc Anesth 2020. Mar 16. pii:
S1053-0770(20)30270-6. doi: 10.1053/j.jvca.2020.03.021.

6©American Society of Echocardiography

ASEcho.org

Figure 1. Suggested algorithm for determining indication for intraoperative transesophageal
echocardiography (TEE)
Abbreviations: LV, left ventricle; RV, right ventricle; PPE, personal protection equipment; TTE,transthoracic echocardiography

7©American Society of Echocardiography

ASEcho.org

Figure 2. Ultrasound system with transesophageal echocardiography capabilities is shown with aplastic cover. The screen, touchable parts and the transducer ports are covered by the disposable
plastic cover.

8©American Society of Echocardiography

ASEcho.org

Table. Suggested stepwise approach to performing a transesophageal echocardiographic
examination (TEE) in a patient with suspected or confirmed COVID-19.
BEFORE PROCEDUREo Don PPE for airborne precaution measures (gown, face shield or goggles, airborne protection mask)o Double glove
o Consider covering the ultrasound system (knobs, screen) with a plastic barrier, including transducer ports
DURING PROCEDUREo Consider using video laryngoscope or direct laryngoscopy to limit contact with patient’s secretionso Limit examination time by performing a focused examo Remove outer gloves and wipe inner gloves with approved viricidal wipes or solution whenever other patient
activities are undertakeno Avoid unnecessary contamination of touchable surfaces of the ultrasound system (knobs, screen)
AFTER PROCEDURE
o Remove TEE probe from patient, disinfect probe and place in closed container and/or biohazard bago Wipe outer gloves, gown, and sleeves with approved viricidal wipes or solutiono Wipe down equipment and probe containero Remove outer glove.
o Remove equipment and probe container to induction room/anteroomo Wipe equipment and probe container with approved viricidal wipes
o Doff PPEo Transport probe in closed container to the cleaning room for immediate cleaning

Abbreviations: PPE, personal protection equipment

9©American Society of Echocardiography

ASEcho.org