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Year : 2020  |  Volume : 30  |  Issue : 1  |  Page : 2-4

Document addressed to cardiovascular echography operators at the time of COVID-19: A Document by the “Società Italiana di Ecocardiografia e CardioVascular Imaging” Board 2019–2021

1 Rehabilitative Cardiology, Ospedale Riabilitativo di Alta Specializzazione di Motta di Livenza (TV), Milano, Italy
2 Monzino Cardiology Center, IRCCS, Milano, Italy
3 Cardiology, AOU Policlinic, University of Catania, Italy
4 Cardiology, Hospital of Desio (MB), Benevento, Italy
5 Cardiology, AOU of Modena, Benevento, Italy
6 Emergency Medicine, S. Antonio Hospital, AO Padova, Benevento, Italy
7 Cardiology, Fatebenefratelli Hospital, Benevento, Italy
8 Cardiology, Dip. CardioNeuroVascolare Aslsudest Toscana, Hospital of Grosseto, Teramo, Italy
9 Geriatrics, AOU Mater-Domini, Catanzaro, Italy
10 Cardiology, “Mazzini” Hospital, Teramo, Italy
11 Cardiology, G.O.M. “Bianchi Melacrino Morelli”, Reggio Calabria, Italy

Date of Submission17-Mar-2020
Date of Acceptance17-Mar-2020
Date of Web Publication13-Apr-2020

Correspondence Address:
Ines Paola Monte
Cardiologia CAST- Policlinico, Via Santa Sofia 76, 95125 Catania
Mauro Pepi
Monzino Cardiology Center, IRCCS, Milano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcecho.jcecho_27_20

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The epidemic of COVID-19 has grown to pandemic proportions and the preventive and mitigation measures have been widely spread through the media. The cardiologists are called as consultants for the cardiovascular pathologies and echocardiography is a fundamental examination in many clinical situations, but not without risks for health staff. Società Italiana di Ecocardiografia e CardioVascular Imaging Council has decided to formulate a document aimed to highlight the importance of a correct indication and execution procedure of the echocardiogram during a COVID-19 pandemic.

Keywords: COVID-19, echocardiography, healthy safety

How to cite this article:
Antonini-Canterin F, Pepi M, Monte IP, Trocino G, Barbieri A, Barchitta A, Ciampi Q, Cresti A, Miceli S, Petrella L, Benedetto F. Document addressed to cardiovascular echography operators at the time of COVID-19: A Document by the “Società Italiana di Ecocardiografia e CardioVascular Imaging” Board 2019–2021. J Cardiovasc Echography 2020;30:2-4

How to cite this URL:
Antonini-Canterin F, Pepi M, Monte IP, Trocino G, Barbieri A, Barchitta A, Ciampi Q, Cresti A, Miceli S, Petrella L, Benedetto F. Document addressed to cardiovascular echography operators at the time of COVID-19: A Document by the “Società Italiana di Ecocardiografia e CardioVascular Imaging” Board 2019–2021. J Cardiovasc Echography [serial online] 2020 [cited 2021 Sep 19];30:2-4. Available from: https://www.jcecho.org/text.asp?2020/30/1/2/282325

  Introduction Top

The epidemic of COVID-19, defined a public health emergency of international concern according to the World Health Organization (WHO),[1] has grown to pandemic proportions, as stated by the WHO itself on the 10th of March. Preventive and mitigation measures, essential on a health and social level, have been widely spread through the media.

According to evidences, the COVID-19 is transmitted from person to person through close contact and droplets.[2] Therefore, the people at higher risk of infection are those who are in close contact with a COVID-19 patient or with those who take care of him/her.

Echocardiography is a fundamental examination in many clinical situations, but the impossibility of maintaining a minimum operator–patient safety distance makes it one of the most dangerous tests for health-care staff.

  Società Italiana Di Ecocardiografia E Cardiovascular Imaging Point of View Top

Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI), as well as other companies, given the importance of this health situation, has decided to formulate a document aimed to highlight the importance of a correct indication and execution procedure of the echocardiogram during a COVID-19 pandemic.

In consideration to the indications on the management of cases in health-care facilities, on specific clinical pathways, on the use of personal protective equipment (PPE) for health-care personnel, and on the standard biosafety precautions variously suggested with notes by the Italian Council of Ministers[3] as well as what specifically indicated by the WHO and for what established by the Prime Ministerial Decree of March 9, 2020, which declines the epidemiological criterions, it is considered necessary to integrate these indications for those who use cardiovascular ultrasound.

SIECVI believes that it is important to ensure the execution of urgent and nondeferrable examinations, leaving the possibility to the cardiologist to be able to refuse the performance of tests not considered appropriate in his/her own judgment and favoring the various possible forms of remote image consulting, thus limiting access to infected areas.[4]

SIECVI draws attention to the use of stationary ultrasound scanners, which should be moved as little as possible from an environment to another favoring the use of an echocardiograph dedicated to infected areas. It also believes must be ensured the training of health personnel on the correct methodologies of wearing and, especially, removing PPE as indicated by the WHO[5] and shown in [Table 1] and [Table 2].
Table 1: Personal protective equipment

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Table 2: Precautions for health-care personnel

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Cleaning and disinfection of the echocardiograph and probes

According to literature, it is demonstrated that coronaviruses (including the ones responsible for SARS and MERS) can survive up to 9 days on inanimate surfaces with optimal humidity and temperature.[6] In-hospital virus transmission via inanimate surfaces has not been demonstrated, but is considered possible.

However, evidence has proved that these coronaviruses can be successfully inactivated by appropriate sanitization procedures using common disinfectants such as sodium hypochlorite (0.%1–0.5%), ethanol (62%–71%), or hydrogen peroxide (0.5%), applied for an adequate period of time. So far, there is no evidence of longer survival or major susceptibility of the SARS 2-CoV to the previously listed disinfectants. Therefore, according to the WHO suggestions, “an accurate cleaning of inanimate surfaces with water and detergents followed by the application of disinfectants commonly used in the hospital setting” is an efficient and sufficient procedure.[7]

Regular cleaning of the echocardiograph can be performed using swabs soaked with 70% alcohol solution, commonly used in hospital setting (e.g. Neoxidina).

Transthoracic probes are used many times and are exposed to several pathogens, secretions, and small amounts of blood from microlesions of the skin or mucosae. Therefore, disinfection must be efficient against every transmissible agent. Cleaning and disinfection procedures must have complex and contradictory characteristics such as effectiveness of disinfection, harmless material, safety for the patient and personnel, and ease of use.

Probes must not be immersed in sodium hypochlorite, sterilized with autoclave or dry heat, whereas gamma rays, ultraviolet, ethylene oxide, and alcohol are impractical. The products which can be used are disinfectant solutions without glutaraldehyde and formol (e.g. the following products can be used: Deconex 53 PLUS, Gigasept Med, Anioxide 1000, Nu-Cidex, and Peracetic acid). Furthermore, quaternary ammonium-based solutions (e.g. Cleanisept Wipes) can be used. However, since not all the detergent solutions are compatible with probes, we suggest to check the maintenance or cleaning manual of each echocardiograph. During cleaning procedures with chemical products, adequate environmental ventilation is required.

During cleaning procedures of devices in contact with COVID-19-positive or suspect patients, the personnel must wear PPE filtering respiratory device FFP2 or FFP3, face shield, goggles, single-use gloves, and long-sleeved water-resistant gown and must follow the rules for the safe removal of the PPE. After the use, PPE must be disposed of as potentially infected material [Table 1], [Table 2], [Table 3].
Table 3: Dressing and undressing in the scrub room

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Management of transesophageal echocardiography and probe

Transesophageal echocardiography can generate aerosol and therefore is a procedure with a high risk of contamination and precautions are necessary [Table 2] and [Table 4]. Latex envelopes for the probe benefit are that they guarantee a good protection against every pathogen, but they do not protect handle and the echocardiograph (false sensation of safety) and cannot be used in patients with allergy to latex. Difficulties in inserting the probe and the inferior quality of images are irrelevant to expert operators and can be solved using contact maneuvers between the probe and latex.
Table 4: Management of transesophageal echocardiography

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  Conclusive Note Top

Documentation of every performed procedure must be registered and stored and must be appropriate for legal examination. The nursing staff must monitor and check the application of the correct procedures for environment management and for endoscope disinfection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization-Situation Report 50. Coronavirus Disease; 2019. Available from: www.who.int/docs/default-source/coronaviruse/situation-reports/20200310. [Last accessed on 2020 Mar 17].  Back to cited text no. 1
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020;395:514-23.  Back to cited text no. 2
Available from: http://www.salute.gov.it/COVD-19. [Last accessed on 2020 Mar 15].  Back to cited text no. 3
Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med 2020. DOI: 10.1056/NEJMp2003539.  Back to cited text no. 4
WHO Interim Guidance 27 February 2020. Available from: http: WHO/2019-nCov/IPC PPE use/2020.1. [Last accessed on 2020 Mar 14].  Back to cited text no. 5
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.  Back to cited text no. 6
World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. World Health Organization; 2020. Available from: /www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 [Last accessed on 2020 Jan 25].  Back to cited text no. 7


  [Table 1], [Table 2], [Table 3], [Table 4]

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