FOCUS TOPIC: ECHOCARDIOGRAPHY IN THE COVID-19 PANDEMIC
ASE STATEMENTS

ASE Statement on Protection of Patients andEchocardiography Service Providers During
the 2019 Novel Coronavirus Outbreak:Endorsed by the American College of
Cardiology
James N. Kirkpatrick, Chair, MD, FASE, Carol Mitchell, PhD, ACS, RDMS, RDCS, FASE, Cynthia Taub, MD,
FASE, Smadar Kort, MD, FASE, Judy Hung, MD, FASE, and Madhav Swaminathan, MD, FASE, Seattle,
Washington; Madison, Wisconsin; Bronx and Stony Brook, New York; Boston, Massachusetts; Durham, North Carolina
Keywords: ASE, COVID-19, Protection statement

This document is endorsed by the following American Society of Echocardiography International Alliance Partners: Argentine Federation of
Cardiology, Argentine Society of Cardiology, ASEAN Society of Echocardiography, Asian-Pacific Association of Echocardiography,
Australasian Sonographers Association, Canadian Society of Echocardiography, Cardiovascular Imaging Society of the Interamerican Society ofCardiology (SISIAC), Chinese Society of Echocardiography, Department of Cardiovascular Imaging of the Brazilian Society of Cardiology,
Echocardiography Section of the Cuban Society of Cardiology, Indian Academy of Echocardiography, Indian Association of CardiovascularThoracic Anaesthesiologists, Indonesian Society of Echocardiography, Iranian Society of Echocardiography, Israel Working Group on
Echocardiography, Japanese Society of Echocardiography, Korean Society of Echocardiography, Mexican Society of Echocardiography andCardiovascular Imaging (SOME-ic), National Society of Echocardiography of Mexico (SONECOM), Philippine Society of Echocardiography,
Saudi Arabian Society of Echocardiography, Thai Society of Echocardiography, Venezuelan Society of Cardiology - Echocardiography Section,
and Vietnamese Society of Echocardiography.

BACKGROUND
The 2019 novel coronavirus, or severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2), which results in coronavirus disease2019 (COVID-19), has been declared a pandemic and is severely
affecting the provision of health care services all over the world.1
Health care workers are at higher risk because this virus is very easily
spread, especially through the kind of close contact involved in theperformance of echocardiographic studies. The virus carries relatively
high mortality and morbidity risk, particularly for certain populations

From the University of Washington Medical Center (J.N.K.), Seattle, Washington;
University of Wisconsin School of Medicine and Public Health (C.M.), Madison,
Wisconsin; Montefiore Medical Center (C.T.), Bronx, New York; Stony Brook
University Medical Center (S.K.), Stony Brook, New York; Massachusetts
General Hospital (J.H.), Boston, Massachusetts; and Duke University (M.S.),
Durham, North Carolina.
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 withinvasive and noninvasive procedures and practice of personal protective equipment. Readers are urged to follow national guidelines and their institutional recommendations regarding best practices to protect their patients and themselves.
These reports are made available by the American Society of Echocardiography(ASE) as a courtesy reference source for its members. The reports contain recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements andrecommendations contained in these reports are primarily based on the opinions

648(the elderly, the chronically ill, the immunocompromised, andpossibly pregnant women).2 Given the risk for cardiovascular complications in the setting of COVID-19, including preexisting cardiac disease, acute cardiac injury, and drug-related myocardial damage,3
echocardiographic services will likely be required in the care of patients with suspected or confirmed COVID-19. Consequently, echocardiography providers will be exposed to SARS-CoV-2.
Sonographers, nurses, advance practice providers, and physicians
have a duty to care for patients and are at the front lines in the battle
against disease. We are at high risk, particularly when we participate inof experts, rather than on scientifically verified data. ASE makes no express or
implied warranties regarding the completeness or accuracy of the information inthese reports, including the warranty of merchantability or fitness for a particularpurpose. In no event shall ASE be liable to you, your patients, or any other third
parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician-patient relationship between
ASE and your patients or anyone else.
Conflicts of interest: None.
Reprint requests: Madhav Swaminathan, MD, FASE, Duke University Medical
Center, Anesthesiology, Box 3094, DUMC Box 3094, Durham, NC 27710(E-mail: madhav.swaminathan@duke.edu).
0894-7317/$36.00
Copyright 2020 by the American Society of Echocardiography.
https://doi.org/10.1016/j.echo.2020.04.001

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the care of patients who are suspected or confirmed to have highly
contagious diseases. Although dedication to patient care is at the heartof our profession, we also have a duty to care for ourselves and our
loved ones and to protect all of our patients by preventing the spreadof disease. This means reducing our own risk while practicing judicious use of personal protective equipment (PPE).
The American Society of Echocardiography (ASE) is committed tothe health, safety, and well-being of our members and the patients weserve. This document is provided to the ASE community as a service
to help guide the practice of echocardiography in this challenging
time. It represents input from a variety of echocardiography practitioners and institutions that have experience with COVID-19 or
have been actively and thoughtfully preparing for it. The circumstances surrounding the outbreak are, of course, extremely dynamic,
and this statement’s recommendations are subject to change. We
direct echocardiography practitioners to the Centers for Disease
Control and Prevention website for the latest updates and recommendations.4
This statement addresses triaging and decision pathways forhandling echocardiography requests, as well as indications and recommended procedures to be followed for an echocardiographic
assessment of cardiovascular function in suspected or confirmed
COVID-19 cases. In addition, we list measures recommended to be
used in the echocardiography laboratory for prevention of disease
spread.

WHOM TO IMAGE?
Review of Indications
Transthoracic echocardiography (TTE), stress echocardiography, andtransesophageal echocardiography (TEE) should be performed only ifthey are expected to provide clinical benefit. The ASE and other societies have established appropriate use criteria to guide imaging.5-8
Echocardiography orders are not yet subject to decision support
tools, as are cardiac magnetic resonance imaging (MRI) and cardiac
computed tomography (CT), but the SARS-CoV-2 outbreak highlights the need to avoid performing rarely appropriate examinations.
Application of the appropriate use criteria represents the first decision
point as to whether an echocardiographic test should be performed.
Second, there are cases in which the indication for echocardiography
is appropriate or may be appropriate, but the examination is unlikely
to yield clinically important information in the short term with theadded risk for potential disease transmission. There are two ways toidentify these studies: Determine which studies are ‘‘elective’’ and reschedule them, performing allothers.
 Identify ‘‘nonelective’’ (urgent or emergent) indications and to defer allothers.

In cases considered for deferral, there is no significant risk to patients in terms of morbidity or mortality and no expected benefit interms of avoiding the use of medical resources (such as emergency
department visits or hospitalizations). These tests should be postponed.
Next, it is important to determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 statusis unknown. Knowing the status of a patient allows the appropriate application of PPE and its conservation when not needed,in addition to reducing the exposure risk to echocardiography
personnel.
TEE carries a heightened risk for spread of the SARS-CoV-2,
because it may provoke aerosolization of a large amount of virus
because of coughing or gagging that may result during the examination. TEE therefore deserves special consideration in determining
when and whether this examination should be performed and underwhat precautions (described below). A cautious consideration of thebenefit of TEE should be weighed against the risk for exposure ofhealth care personnel to aerosolization in a patient with suspected
or confirmed COVID-19 and the use of PPE. TEE should be postponed or canceled if an alternative imaging modality (e.g., off-axis
TTE, ultrasound-enhancing agent with TTE) can provide the necessary information. Contrast-enhanced CT and MRI have emerged asalternatives to TEE for the exclusion of left atrial appendage thrombus
before cardioversion.9 The use of these tests to avoid an aerosolizing
procedure should be balanced against the risk of transporting a patient through the hospital to the computed tomographic or MRI scanner, the need to disinfect the CTor MRI room, and iodinated contrast
and radiation for CT and long scan times for MRI. Some institutions
have dedicated computed tomographic scanners reserved for patients with COVID-19.
Similarly, treadmill and bicycle stress echocardiography in patientswith COVID-19 may lead to exposure because of deep breathing
and/or coughing during exercise. These tests should generally be deferred or converted to pharmacologic stress echocardiography.
Depending on the trajectory of the outbreak, some institutions
may face a crisis state with reduced availability of trained staff and/or equipment. In this setting, triage by indication may be necessary,deciding which appropriate and urgent or emergent echocardiographic studies will be performed and which will not, or deciding
which will be performed first. This prioritization of indications willneed to be done on a case-by-case basis, while accounting for many
patient-level factors such as current indication, current clinical status,
medical history, and the results of other tests. Involving referring physicians in the triage process is therefore essential.
WHERE TO IMAGE?
The portability of echocardiography affords a clear advantage in imaging patients without having to move them and risk virus transmission in the clinic or hospital. All forms of echocardiography(including chemical stress tests) can be performed in emergency departments, hospital wards, intensive care units, operating theaters, recovery areas, and structural heart and electrophysiology procedurelaboratories, in addition to echocardiography laboratories.
Identifying the optimal location for an echocardiographic study requires minimizing the risk for virus transmission but also considering
monitoring capabilities and staffing of different locations. For
example, patients with suspected or confirmed COVID-19 are placedin isolation rooms, and echocardiography performed in the patient’s
room can prevent transit to other areas of the hospital, risking wider
exposure. However, it may not be possible to perform TEE or stressechocardiography in the room, because of staffing or insufficientmonitoring equipment.
In the outpatient setting, patients should be screened for infection
according to local protocols and methods for quarantine. Some institutions have set aside separate rooms and separate machines for patients with suspected or confirmed infection.

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HIGHLIGHTS ASE guidance for patient and provider protection during echo
exams in the COVID-19 pandemic.
 Triaging approach for prioritizing echo exams during the
COVID-19 pandemic.
 Recommended imaging approach and appropriate PPE use
during echo exams.
HOW TO IMAGE?
Protocols
Cardiac imaging is performed by a wide variety of operators using awide variety of machines and a wide variety of protocols.
Ultrasound-assisted physical examination (UAPE), point-of-care cardiac ultrasound (POCUS), critical care echocardiography, limited
and comprehensive traditional TTE, TEE, and stress echocardiography all can play a role in caring for patients with suspected orconfirmed COVID-19. UAPE and POCUS examinations performedby the clinicians who are already caring for these patients at bedsidepresent an attractive option to screen for important cardiovascularfindings, elucidate cardiac contributions to symptoms or signs, triage
patients in need of full-feature echocardiographic services, andeven, perhaps, identify early ventricular dysfunction during
COVID-19 infection, all without exposing others and using additional
resources. Depending on the capabilities of the machines used, images obtained by UAPE, POCUS, and critical care echocardiography
practitioners can often be saved to allow remote interpretive assistance from more experienced echocardiographers. Archiving theseimages for review should help focus future imaging studies and provide comparisons of cardiac structure and function over time. In
some cases, review of these images by a consulting cardiovascularspecialist may obviate the need for echocardiography (and therefore
reduce staff exposure), as pertinent clinical questions will beanswered (e.g., etiology of hypotension). In other cases, they will indicate the need for more advanced imaging (e.g., wall motion and quantitative valvular assessment). Therefore, these images should be saved
and archived whenever possible. Some devices use a camera thatallows a sonographer or another imaging expert to remotely guideprobe placement.
Along the same lines, echocardiographic studies performed on patients with suspected or confirmed COVID-19 should be as focused
as necessary to obtain diagnostic views but should also be comprehensive enough to avoid the need to return for additional images.

Each study should be tailored to the indication and planned inadvance, after review of images from past examinations and other imaging modalities. Complete examinations may be necessary in somecircumstances. Plans for ultrasound-enhancing agent (UEA) use
should be made in advance to prevent a sonographer’s having to
wait for the agent to be delivered or having to use more PPE to exit
the patient’s room to obtain the agent. Although the safety of UEAs
specifically in patients with COVID-19 has not yet been determined,
they have been used and proved safe in patients in intensive careunits. The use of UEAs may therefore be considered in such cases
as long as the benefits in terms of diagnostic yield and scan time arefavorable.
Regardless of the type of study (UAPE, POCUS, critical care echocardiography, or comprehensive echocardiography), prolonged scanning can expose these clinicians to added risk. An additional
consideration when performing limited TTE is the limitations that
may be posed by layers of protective equipment on image quality.
Therefore, these studies should not be performed by a sonography
student or any other novice or inexperienced practitioner, to minimize
scanning time while obtaining images of the highest possible quality.
Finally, the results of the examination should be rapidly reviewed
and key findings recorded immediately on the patient’s recordand communicated to the primary care team to allow hemodynamic
management to be optimized.
The group therefore recommends the following: Echocardiographic examinations should be planned ahead, on the basis ofindications, clinical information, laboratory data, and other imaging findings,
to allow a focused sequence of images that help with management decisions.
 The use of UEAs should be considered before an examination to avoid theneed to prolong scan time while awaiting preparation of the agent.
 Scan times should be minimized by excluding students or novice practitioners from performing imaging.
 The imaging team should ensure rapid review and reporting of key findingsin the patient’s record and communicating them with the primary care team.

Protection
Personnel. Imaging should be performed according to local standards for the prevention of virus spread. Meticulous and frequent
hand washing is crucial. At some institutions, the level of PPE required
may depend on the risk level of the patient with regard to COVID-19(minimal risk when COVID-19 is not suspected, moderate risk when
it is suspected, and high risk when it is confirmed). At some institutions, suspected and confirmed cases are treated similarly. The typesof PPE can be divided into levels or categories (see Table 1):

Table 1 Precaution types and PPE
Hand washing

Gloves/double
glovesIsolation
gown

Surgical mask

X*

Standard

X

X

Special droplet

X

X

X

Airborne†

X

X

X

N-95 or
N-99 mask

Face shield

PAPR system

Surgical cap

Shoe cover

X*

X

X

X

X

X

X

X

X

X

X

PAPR, Powered air -purifying respirator.
This is a general guide based on current practice and recommendations at the present time and is subject to change and modification to fit local
procedures and practice patterns.
*Surgical mask may be used for droplet precautions to conserve N-95 or N-99 respirators.
†
Patient location may determine level of protection (e.g., airborne precautions used for all patients in the intensive care unit setting).

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No

COVID-19
suspected/conﬁrmed

Standard Precauons (Consider
droplet precauons for TEE)

No
Defer/reschedule

Yes

TTE/Stress

1.
2.
3.
4.

Is an echo
indicated at
this me?

SpecialConsideraons

All TEE

Echo Lab
Ward
Cath/EP Lab
ED

1. ICU
2. Operang room
3. Invasive venlaon

DropletPrecauons

Airborne
Precauons

Protocols
Airborne
Precauons

•
•

POCUS
Focused imaging

ProteconLimit Staﬀ Parcipaon•
Essenal Personnel only•
Limit Exposure•>60•
Chronically ill•
Immunocompromised•
Pregnant

Figure 1 Suggested algorithm for determining indication and level of protection. ED, Emergency department; EP, electrophysiology;
ICU, intensive care unit.
 Standard care involves hand washing or hand sanitization and use of gloves.
The use of a surgical face mask in this setting may also be considered.
 Droplet precautions include gown, gloves, head cover, face mask, and eye
shield.
 Airborne precautions add special masks (e.g., N-95 or N-99 respirator
masks, powered air-purifying respirator systems) and shoe covers.

The local application of each component of PPE can vary according
to the level or type of risk for TTE and stress echocardiography, butairborne precautions are required during TEE for suspected andconfirmed cases, because of the increased risk for aerosolization.
Surgical face masks for patients are recommended for those who are
symptomatic and undergoing surface echocardiographic examinations,provided institutional resources allow this strategy for source control.10
It is important to reiterate that the type of PPE to be used in specificcases will depend on local institutional policy and resources. The
Centers for Disease Control and Prevention provides updated guidelines for PPE use for health care workers.4 The suggested approach toperforming echocardiographic procedures and level of PPE is provided in Figure 1.
Equipment. Equipment care is critical in the prevention of transmission. Some institutions cover probes and machine consoles withdisposable plastic and forgo the use of electrocardiographic stickers.
It is important to note that the benefit of using protective covers
must be balanced against the potential for suboptimal images and prolongation of scan time. Some institutions set aside certain machines orprobes for use on patients with suspected or confirmed infection.
Although SARS-CoV-2 is sensitive to most standard viricidal disinfectant solutions, care must be taken when cleaning. Local standards vary,
but echocardiographic machines and probes should be thoroughly
cleaned, ideally in the patient’s room and again in the hallway.
Smaller, laptop-sized portable machines are more easily cleaned, but
use of these machines should be balanced against potential tradeoffs in image quality and functionality. Please consult vendors’ disin-

fecting guidelines, available on their websites, as procedures varyand could affect the functionality of machines. Transesophageal echocardiographic probes should undergo cleaning in the room (including
the handle and cord) and then be transferred in a closed container tobe immediately disinfected according to the manufacturer’s recommendations. The exact steps to be followed for disinfection of the
TEE probe and equipment will depend on local institutional protocols
that usually are guided by infectious disease experts and resource availability. The American Institute for Ultrasound in Medicine has specificguidelines for disinfection of ultrasound equipment.11
Role of Learners. The performance and interpretation of echocardiographic studies, especially those in suspected or confirmed COVD19 cases, should be limited to essential personnel. For TEE, practices
may vary, but there should be at most one person to handle the probe
and another to operate the machine controls, along with another toadminister sedation. Medical education remains important, and echocardiographic practitioners play a crucial role in teaching essential
components of cardiovascular medicine, as well as scanning and interpretation skills, to a wide variety of learners. Medical and sonography
students, residents, fellows, and practicing physicians gain knowledge
and experience through rotations on echocardiography services,
through observing the performance of studies, hands-on scanning,
and reading with experts. In the current environment, however, elective rotations should be suspended, and restrictions should be placedon trainees who are not essential to clinical care. At many institutions,advanced trainees (e.g., fellows) provide crucial off-hours scanningand interpretation but must follow all applicable procedures to reduce
infection transmission. Training and education can be moved ‘‘online.’’The ASE and others provide multiple educational offerings, including
webinars and lectures. A variety of simulators are available to teachscanning skills without involving patients.
Other Considerations. In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should

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Figure 2 Summary recommendations.
be given to limiting the exposure of staff members who may be particularly susceptible to severe complications of COVID-19. Staff members who are >60 years of age, have chronic conditions, are
immunocompromised, or are pregnant may wish to avoid contact
with patients suspected or confirmed to have COVID-19, dependingon local procedures.
The risk for transmission also is present in reading rooms. Keyboards,
monitors, mice, chairs, phones, desktops, and doorknobs should befrequently cleaned and ventilation provided wherever possible. At
some institutions, the echocardiography laboratory reading room is aplace where many clinical services congregate to review images. In
the current environment, it may be advisable to ask these services to review images remotely while speaking with the echocardiographerconsultant by phone, or review images together in a webinar.
CONCLUSION
The provision of echocardiographic services remains crucial in thisdifficult time of the SARS-CoV-2 outbreak. Working together, we
can continue to provide high-quality care while minimizing risk toourselves, our patients, and the public at large. Carefully considering
whom to image, where to image, and how to image has the potential
to reduce the risk for transmission. A summary of these recommendations is provided in Figure 2.
ACKNOWLEDGMENTS
This statement was prepared by James Kirkpatrick, MD, Carol
Mitchell, Smadar Kort, MD, Judy Hung, MD, Cynthia Taub, MD,
and Madhav Swaminathan, MD, and approved by the ASE executive
committee on March 24, 2020. Protocols and procedures used in the
preparation of this document courtesy of Madhav Swaminathan(Duke University, Durham, NC), Muhammad Saric (New York
University Medical Langone Medical Center, New York), Mingxing
Xie (Union Hospital, Tongji Medical College, Huazhong Universityof Science and Technology, Wuhan, China), Cynthia Taub(Montefiore Medical Center, Albert Einstein College of Medicine,Bronx, NY), Lissa Sugeng (Yale University, New Haven, CT),
Smadar Kort (Stony Brook University, Stony Brook, NY), Judy
Hung (Massachusetts General Hospital, Boston, MA), Marielle
Scherer-Crosbie (University of Pennsylvania, Philadelphia, PA), Ray
Stainback (Baylor St. Luke’s Medical Center, Houston, TX), andJames Kirkpatrick (University of Washington, Seattle, WA).
Additional guidance was provided by the British Society of
Echocardiography and Societa Italiana di Ecocardiograpfia eCardiovascular Imaging.
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