Perioperative Echocardiography During the Coronavirus Crisis: Considerations in Pediatrics and Congenital Heart Disease

Abstract

THE CURRENT coronavirus crisis is now a pandemic, presenting multiple challenges to the conduct and practice of echocardiography, including the risks of infection.1He H. Zhao S. Han L. et al.Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome coronavirus-2 infection.J Cardiothorac Vasc Anesth. 2020 Mar 16; ([E-pub ahead of print] Accessed April 7, 2020)https://doi.org/10.1053/j.jvca.2020.03.021Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 2He Y. Wei J. Bian J. et al.Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease-2019.J Cardiothorac Vasc Anesth. 2020 Mar 30; ([E-pub ahead of print] Accessed April 7, 2020)https://doi.org/10.1053/j.jvca.2020.03.026Abstract Full Text Full Text PDF Scopus (31) Google Scholar, 3Li W. Huang J. Guo X. et al.Anesthesia management and perioperative infection control in patients with the novel coronavirus.J Cardiothorac Vasc Anesth. 2020 Mar 29; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.035Abstract Full Text Full Text PDF Scopus (18) Google Scholar The management of perioperative echocardiography in suspected and infected pediatric patients requires careful consideration of this infectious risk, including personal protective equipment.3Li W. Huang J. Guo X. et al.Anesthesia management and perioperative infection control in patients with the novel coronavirus.J Cardiothorac Vasc Anesth. 2020 Mar 29; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.035Abstract Full Text Full Text PDF Scopus (18) Google Scholar,4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar These significant considerations recently prompted specific statements for echocardiography in these settings from the American Society of Echocardiography, the British Society of Echocardiography, and the Italian Society of Echocardiography and Cardiovascular Imaging.5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar The unique considerations for echocardiography in pediatrics and congenital heart disease now also have received due attention.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar The purpose of this freestanding editorial is to provide perspectives on this important disease for the perioperative echocardiographic community with respect to pediatric and congenital heart disease patients. The indications, venue, and approaches for imaging are discussed for these settings to offer a framework to navigate these compelling considerations in pediatric practice. These recommendations are examined from the perspective of the cardiovascular anesthesiologist and perioperative echocardiographer to encourage best practices in this clinical arena. The provided references also can assist policy leaders in their management of the pandemic at their institutions. Pediatric echocardiography, including transthoracic, transesophageal, and fetal imaging, has established indications and procedures.9The Intersocietal Accreditation Commission. The IAC standards and guidelines for pediatric echocardiography accreditation. Available at:https://www.intersocietal.org/echo/standards/IACPediatricEchocardiographyStandards2017.pdf. Accessed April 8, 2020.Google Scholar,10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar Based on published appropriate-use criteria for pediatric echocardiography, the indication for an echocardiographic examination is considered appropriate when the expected incremental information, combined with clinical judgment, exceed the expected risks to an acceptable and reasonable degree.10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar,11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar Furthermore, an indication for echocardiographic imaging has been classified into 1 of the following 3 categories: generally appropriate (as reflected by a median panel score of 7-9), may be appropriate (as reflected by a median panel score of 4-6), and rarely appropriate (as reflected by a median panel score of 1-3).10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar, 11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar, 12Sachdeva R. Samai C. Vintcent R.N. Pediatric appropriate use criteria for echocardiography: Implications for clinical practice.Pediatrics. 2015; 135: e1128-e1130Crossref PubMed Scopus (8) Google Scholar The goal of this scale of appropriate-use criteria has been to minimize echocardiography examinations in pediatric practice for rarely appropriate criteria.10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar, 11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar, 12Sachdeva R. Samai C. Vintcent R.N. Pediatric appropriate use criteria for echocardiography: Implications for clinical practice.Pediatrics. 2015; 135: e1128-e1130Crossref PubMed Scopus (8) Google Scholar With the advent of the coronavirus crisis and the potentially life-threatening risks of infection, the imaging indication in pediatric echocardiography should be screened carefully, with a preference for delaying examinations that are either elective or rarely appropriate in accordance with institutional practice.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar, 9The Intersocietal Accreditation Commission. The IAC standards and guidelines for pediatric echocardiography accreditation. Available at:https://www.intersocietal.org/echo/standards/IACPediatricEchocardiographyStandards2017.pdf. Accessed April 8, 2020.Google Scholar, 10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar, 11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar, 12Sachdeva R. Samai C. Vintcent R.N. Pediatric appropriate use criteria for echocardiography: Implications for clinical practice.Pediatrics. 2015; 135: e1128-e1130Crossref PubMed Scopus (8) Google Scholar Emergency examinations in pediatric echocardiography with strong indications therefore have a high priority to proceed. Given that the intensity of the coronavirus crisis is variable and dynamic, the triage of echocardiography examinations must remain agile and responsive to local conditions.13Al-Ghofaily L. Feinman J.W. Augoustides J.G. Fellowship training in adult cardiothoracic anesthesiology – navigating the new educational landscape due to the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 18, 2020)https://doi.org/10.1053/j.jvca.2020.04.019Abstract Full Text Full Text PDF Scopus (7) Google Scholar This management process also should focus on strict infection control.1He H. Zhao S. Han L. et al.Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome coronavirus-2 infection.J Cardiothorac Vasc Anesth. 2020 Mar 16; ([E-pub ahead of print] Accessed April 7, 2020)https://doi.org/10.1053/j.jvca.2020.03.021Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 2He Y. Wei J. Bian J. et al.Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease-2019.J Cardiothorac Vasc Anesth. 2020 Mar 30; ([E-pub ahead of print] Accessed April 7, 2020)https://doi.org/10.1053/j.jvca.2020.03.026Abstract Full Text Full Text PDF Scopus (31) Google Scholar, 3Li W. Huang J. Guo X. et al.Anesthesia management and perioperative infection control in patients with the novel coronavirus.J Cardiothorac Vasc Anesth. 2020 Mar 29; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.035Abstract Full Text Full Text PDF Scopus (18) Google Scholar Fetal echocardiography also should be triaged based on published levels of risk.14Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and management of fetal cardiac disease: A scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (694) Google Scholar A fetal echocardiogram for a low-risk patient typically will have a low-risk referral indication in the setting of a normal cardiac screening examination and as such has a low priority for additional consideration during the peak of the coronavirus crisis.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar,14Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and management of fetal cardiac disease: A scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (694) Google Scholar A fetal echocardiogram for a moderate-risk patient typically will be indicated by a moderate-to-high risk referral indication with a gestational age greater than 24 weeks or by confirmed congenital heart disease with a gestational age less than 34 weeks.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar,14Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and management of fetal cardiac disease: A scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (694) Google Scholar These examinations typically can be rescheduled after the peak of the crisis has passed.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar A fetal echocardiogram for high-risk patients typically will include an urgent clinical indication, or a moderate-to-high risk referral indication with a gestational age less than 24 weeks, or confirmed congenital heart disease with a gestational age more than 34 weeks.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar,14Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and management of fetal cardiac disease: A scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (694) Google Scholar The examinations in this category should be scheduled as soon as possible. The details of this management process have been fully covered in the provided references and are beyond the scope of this editorial.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar, 9The Intersocietal Accreditation Commission. The IAC standards and guidelines for pediatric echocardiography accreditation. Available at:https://www.intersocietal.org/echo/standards/IACPediatricEchocardiographyStandards2017.pdf. Accessed April 8, 2020.Google Scholar, 10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar, 11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar, 12Sachdeva R. Samai C. Vintcent R.N. Pediatric appropriate use criteria for echocardiography: Implications for clinical practice.Pediatrics. 2015; 135: e1128-e1130Crossref PubMed Scopus (8) Google Scholar,14Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and management of fetal cardiac disease: A scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (694) Google Scholar Transesophageal imaging is considered high risk because it is associated with viral aerosolization and consequent increased risk of transmission.15Bowdle A. Munoz-Price LS. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics.Anesthesiology. Mar 25 2020; ([E-pub ahead of print] Accessed April 10, 2020)https://doi.org/10.1097/ALN.0000000000003295Crossref PubMed Scopus (42) Google Scholar,16Greenland J.R. Michelow M.D. Wang L. et al.COVID-19 infection – implications for perioperative and critical care physicians.Anesthesiology. 2020 Mar 27; ([E-pub ahead of print] Accessed April 11, 2020)https://doi.org/10.1097/ALN.0000000000003303Crossref PubMed Scopus (152) Google Scholar Consequently, the threshold for this imaging modality in pediatric practice should be high during the coronavirus crisis. These examinations have low priority in the setting of a weak indication, borderline clinical effect, or if an alternative imaging modality could be diagnostic, according to published consensus and guidelines.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar, 9The Intersocietal Accreditation Commission. The IAC standards and guidelines for pediatric echocardiography accreditation. Available at:https://www.intersocietal.org/echo/standards/IACPediatricEchocardiographyStandards2017.pdf. Accessed April 8, 2020.Google Scholar, 10Campbell R.M. Douglas P.S. Eiden B.W. et al.ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient echocardiographic cardiology.J Am Coll Cardiol. 2014; 64: 2039-2060Crossref PubMed Scopus (87) Google Scholar, 11Sachdeva R. Valente A.M. Armstrong A.K. et al.ACC/AHA/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease.J Am Coll Cardiol. 2020; 75: 657-703Crossref PubMed Scopus (53) Google Scholar, 12Sachdeva R. Samai C. Vintcent R.N. Pediatric appropriate use criteria for echocardiography: Implications for clinical practice.Pediatrics. 2015; 135: e1128-e1130Crossref PubMed Scopus (8) Google Scholar Echocardiographic examinations may be possible at the point of care by the clinicians already taking care of these children with suspected or proven coronavirus infection.17Sanders J.A. Navas-Blanco J.R. Yeldo N.S. et al.Incorporating perioperative point-of-care ultrasound as part of the anesthesia residency curriculum.J Cardiothorac Vasc Anesth. 2019; 33: 2414-2418Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 18Beaubien-Souligny W. Denault A. Robillard P. et al. The role of point-of-care ultrasound monitoring in cardiac surgical patients with acute kidney injury.J Cardiothorac Vasc Anesth. 2019; 33: 2781-2796Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 19Dong Y. Mo X. Hu Y. et al.Epidemiology of COVID-19 among children in China.Pediatrics. 2020; ([E-pub ahead of print] Accessed April 12, 2020)https://doi.org/10.1542/peds.2020-0702Crossref Scopus (2362) Google Scholar This approach is advantageous not only for patient convenience but also for infection control. The final location for an echocardiographic examination often will require thoughtful consideration of the following: risk of viral transmission, including pregnant women; monitoring capabilities; and staffing requirements.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar A complicating factor in pediatric practice is that children with this infection often may be asymptomatic.20Cruz A. Zeichner S. COVID-19 in children: Initial characterization of the pediatric disease.Pediatrics. 2020; ([E-pub ahead of print] Accessed April 12, 2020)https://doi.org/10.1542/peds.2020-0834Crossref Scopus (209) Google Scholar,21Chen X. Liu Y. Gong Y. et al.Perioperative management of patients infected with the novel coronavirus: Recommendations from the joint task force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists.Anesthesiology. 2020 Mar 26; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1097/ALN.0000000000003301Crossref Scopus (169) Google Scholar In certain circumstances, such as the peak of the coronavirus crisis, it may be reasonable to test new pediatric hospital admissions for this infection to guide the choice of appropriate measures, including infection control.2He Y. Wei J. Bian J. et al.Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease-2019.J Cardiothorac Vasc Anesth. 2020 Mar 30; ([E-pub ahead of print] Accessed April 7, 2020)https://doi.org/10.1053/j.jvca.2020.03.026Abstract Full Text Full Text PDF Scopus (31) Google Scholar,3Li W. Huang J. Guo X. et al.Anesthesia management and perioperative infection control in patients with the novel coronavirus.J Cardiothorac Vasc Anesth. 2020 Mar 29; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.035Abstract Full Text Full Text PDF Scopus (18) Google Scholar,8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar In the operating room environment, transesophageal echocardiography often is performed in the setting of a secure airway.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar This approach to airway management can minimize aerosolization of viral particles and contain viral spread.21Chen X. Liu Y. Gong Y. et al.Perioperative management of patients infected with the novel coronavirus: Recommendations from the joint task force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists.Anesthesiology. 2020 Mar 26; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1097/ALN.0000000000003301Crossref Scopus (169) Google Scholar,22Meng L. Qui H. Wan L. et al.Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience.Anesthesiology. 2020 Mar 26; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1097/ALN.0000000000003296Crossref Scopus (366) Google Scholar The conduct of transesophageal imaging in the setting of pediatric coronavirus infection should consider current recommendations indexed to institutional practice and the intensity of the coronavirus crisis.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar There may be dedicated probes and machines in this pediatric setting, depending on local factors.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar The conduct of the echocardiographic examination in children with suspected or confirmed coronavirus infection should be tailored to address the clinical question.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar The cardiac manifestations of COVID-19, such as pericarditis and myocarditis, should be considered during this focused examination.23Augoustides JG. Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.04.001Abstract Full Text Full Text PDF Scopus (13) Google Scholar Prolonged echocardiographic examinations should be minimized to limit exposure, given that infectious risks likely are present in asymptomatic children during the crisis phase of COVID-19.21Chen X. Liu Y. Gong Y. et al.Perioperative management of patients infected with the novel coronavirus: Recommendations from the joint task force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists.Anesthesiology. 2020 Mar 26; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1097/ALN.0000000000003301Crossref Scopus (169) Google Scholar, 22Meng L. Qui H. Wan L. et al.Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience.Anesthesiology. 2020 Mar 26; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1097/ALN.0000000000003296Crossref Scopus (366) Google Scholar, 23Augoustides JG. Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.04.001Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar Consequently, an experienced practitioner should complete the examination in a focused, time-efficient but comprehensive fashion.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar Even though this strategy may erode the educational environment, the safety of learners and trainees is more important, as outlined clearly by the Accreditation Council for Graduate Medical Education (full details available at www.acgme.org/covid-19).24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar Apart from the imaging protocol, the conduct of the pediatric echocardiographic examination should take place according to institutional standards for infection control during the crisis, including adequate barrier techniques.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar The degree of personal protective equipment will depend on level of infectious risk as defined by specific testing, institutional protocol, and the level of the pandemic at a given hospital.6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar Clinical symptoms in infected children often may be absent, prompting interim strategies such as testing all hospitalized children as needed or raising the index of suspicion for active infection. Airborne precautions against viral droplet infection include N95 and N99 masks and powered air purifying respirators.15Bowdle A. Munoz-Price LS. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics.Anesthesiology. Mar 25 2020; ([E-pub ahead of print] Accessed April 10, 2020)https://doi.org/10.1097/ALN.0000000000003295Crossref PubMed Scopus (42) Google Scholar,16Greenland J.R. Michelow M.D. Wang L. et al.COVID-19 infection – implications for perioperative and critical care physicians.Anesthesiology. 2020 Mar 27; ([E-pub ahead of print] Accessed April 11, 2020)https://doi.org/10.1097/ALN.0000000000003303Crossref PubMed Scopus (152) Google Scholar Transesophageal imaging in suspected or confirmed coronavirus-infected patients carries a heightened risk of viral transmission because of the increased load from viral aerosolization.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar It may be reasonable during the height of the crisis to assume that all children who require transesophageal examinations are positive for the infection. In the setting of a protocol for disease testing, a documented negative test within 48- to- 72 hours may be considered adequate at some institutions to conduct the examination with standard precautions such as eye protection, mask, and gloves rather than the enhanced standards with full personal protective equipment.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar In pediatric patients for whom testing results are unknown and who have an endotracheal tube before arrival in the operating room or interventional suite, the risk of viral transmission from aerosolization is considered low.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar How should the risks of viral aerosolization be managed in asymptomatic untested children who have not undergone tracheal intubation and who require transesophageal imaging in the operating room or interventional suite? In this scenario, it is reasonable to expect that the infectious risk is high, assuming that these children may be positive for infection and that endotracheal intubation generates a high load of aerosolized viral particles.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar In this setting, airway management and probe placement likely should proceed with maximal barrier precautions, including personal protective equipment and consideration for air turnover in the given space.8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar It also is reasonable that the transesophageal probe be placed and positioned by the airway team during aerosol precautions to minimize operator and infectious risks.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar In the setting of children with known positive infection, full isolation and aerosol precautions should apply not only for the conduct of the echocardiographic examination but also the overall care of those pediatric patients.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar,8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar,15Bowdle A. Munoz-Price LS. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics.Anesthesiology. Mar 25 2020; ([E-pub ahead of print] Accessed April 10, 2020)https://doi.org/10.1097/ALN.0000000000003295Crossref PubMed Scopus (42) Google Scholar,16Greenland J.R. Michelow M.D. Wang L. et al.COVID-19 infection – implications for perioperative and critical care physicians.Anesthesiology. 2020 Mar 27; ([E-pub ahead of print] Accessed April 11, 2020)https://doi.org/10.1097/ALN.0000000000003303Crossref PubMed Scopus (152) Google Scholar The intensity of the coronavirus crisis at a given institution challenges in many ways not only the imaging protocols but also the infectious control procedures for pediatric perioperative echocardiography. An additional consideration for infection control concerns the appropriate care of echocardiographic equipment (the “hardware”) to minimize the risks of viral transmission.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar The relevant probes and machine consoles may be covered with disposable plastic. Depending on institutional circumstances, certain hardware can be specifically designated for imaging of suspected or confirmed pediatric cases of coronavirus infection.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar, 5American Society of Echocardiography. Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. Available at: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. Accessed April 7, 2020.Google Scholar, 6British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://bsecho.org/covid19. Accessed April 7, 2020.Google Scholar, 7Italian Society of Echocardiography and Cardiovascular Imaging. Statement about echocardiography during the COVID-19 pandemic. Available at: https://www.siec.it/documento-ad-uso-degli-operatori-di-ecografia-cardiovascolare-per-covid-19/. Accessed April 7, 2020.Google Scholar, 8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar Although most disinfectant solutions are virucidal, all echocardiographic equipment should be processed thoroughly for the goals of viral clearance and hardware functionality with maximal protection of patients and ultrasound providers.25American Institute for Ultrasound in Medicine. Guidelines for cleaning and preparing external and internal-use ultrasound transducers between patients and safe handling and use of ultrasound coupling gel. Available at: https://www.aium.org/officialStatements/57. Accessed April 8, 2020.Google Scholar, 26American Institute for Ultrasound in Medicine. Quick guide on COVID-19 protections - ultrasound transducers, equipment, and gel. Available at: https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_UTEG.pdf. Accessed April 8, 2020.Google Scholar, 27American Institute for Ultrasound in Medicine. Quick guide on COVID-19 protections – patients and ultrasound provider protection. Available at: https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_PUPP.pdf. Accessed April 8, 2020.Google Scholar Despite the variations in sanitation protocols, these standards should comply with the recommendations from the American Institute for Ultrasound in Medicine to balance infectious risks with imaging performance.4Augoustides J.G. Perioperative echocardiography – key considerations during the coronavirus pandemic.J Cardiothorac Vasc Anesth. 2020 Mar 28; ([E-pub ahead of print] Accessed April 8, 2020)https://doi.org/10.1053/j.jvca.2020.03.0462020Crossref Google Scholar,8Barker P.C.A. Lewin M.B. Donofrio M.T. et al.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.J Am Soc Echocardiogr. 2020 Apr 9; ([E-pub ahead of print])PubMed Google Scholar,25American Institute for Ultrasound in Medicine. Guidelines for cleaning and preparing external and internal-use ultrasound transducers between patients and safe handling and use of ultrasound coupling gel. Available at: https://www.aium.org/officialStatements/57. Accessed April 8, 2020.Google Scholar, 26American Institute for Ultrasound in Medicine. Quick guide on COVID-19 protections - ultrasound transducers, equipment, and gel. Available at: https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_UTEG.pdf. Accessed April 8, 2020.Google Scholar, 27American Institute for Ultrasound in Medicine. Quick guide on COVID-19 protections – patients and ultrasound provider protection. Available at: https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_PUPP.pdf. Accessed April 8, 2020.Google Scholar Education and teaching in pediatric echocardiography are important.13Al-Ghofaily L. Feinman J.W. Augoustides J.G. Fellowship training in adult cardiothoracic anesthesiology – navigating the new educational landscape due to the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 18, 2020)https://doi.org/10.1053/j.jvca.2020.04.019Abstract Full Text Full Text PDF Scopus (7) Google Scholar,24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar During the coronavirus crisis, however, learner well-being has a higher priority.24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar In this stressful clinical learning environment, it is reasonable to cancel elective rotations and to restrict trainee exposure.24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar Furthermore, education in echocardiography can be transitioned to distance-based learning, including remote conferencing technology.24Al- Ghofaily L. Feinman J.W. Augoustides J.G. The fellowship milieu in adult cardiothoracic anesthesiology – fostering psychological wellbeing during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; ([E-pub ahead of print] Accessed April 26, 2020)https://doi.org/10.1053/j.jvca.2020.04.031Abstract Full Text Full Text PDF Scopus (5) Google Scholar The protection of echocardiography personnel can be enhanced further by thoughtful assignments for staff with risk factors for severe infection such as advanced age, chronic conditions, immunosuppression, and pregnancy. The coronavirus pandemic has significantly affected the conduct of pediatric echocardiography in the perioperative setting. Careful consideration of the indications, venues, and approaches for echocardiographic imaging will both optimize patient care and infection control during the crisis.