ABC | Volume 115, Nº1, July 2020

Review Article Costa et al. Cardiovascular Imaging and Interventional Procedures Arq Bras Cardiol. 2020; 115(1):111-126 d) Left atrial appendage closure: should be postponed. e) Other procedures: should be postponed unless urgent hospitalization is required. 5.7. Reducing the Spread of COVID-19 5.7.1. Reducing droplets spreading: Involves measures such as the use of surgical mask by patients with suspected or confirmed COVID-19. All nonessential equipment should be moved out of the CCL procedure room or covered with clear drapes before the patient’s arrival to the room. In addition, it is worth emphasizing the importance of reducing circulation in the procedure room to minimize exposure and infection spread. 50 Deep cleaning and thorough disinfection of the room after CCL procedures involving patients with COVID-19 are important to control the infection. In addition, disinfection with ultraviolet radiation can be used. Thorough cleaning might require an extra time; thus, if feasible, a procedure in a patient with COVID-19 should be performed as the final one of the day. Whenever possible, the patient with suspected or confirmed COVID-19 should undergo bedside procedures (transient pacemaker, intra-aortic balloon) aiming at minimizing the need for moving the patient out from an isolation room and preventing the risk of additional exposure via transportation to the CCL. 50 5.7.2. Patients requiring intubation, aspiration or cardiopulmonary resuscitation: Intubation, aspiration and active cardiopulmonary resuscitation can generate aerosol particles from respiratory secretions, increasing the likelihood of personal exposure. 54 Patients already intubated pose a lower contamination risk to healthcare personnel, because they are on closed-loop ventilation. 55 For patients with suspected or confirmed COVID-19 who need orotracheal intubation, this intervention should be performed before arrival to the CCL. In addition, intubation should be considered as early as possible in borderline patients to avoid the need for an urgent intubation in the CCL. 55 The cooperation of the intensive care and anesthesia staffs for airway management is fundamental to prevent the infection spread. 5.8. Dedicated Catheterization Laboratory Having a dedicated room for the care of suspected/ positive COVID-19 cases is aimed at reducing the risk of infection for health professionals and minimizing the viral contamination of other rooms. In CCLs with more than one procedure room, one should be dedicated to COVID-19 and another to ‘clean’ procedures. This is no guarantee that the ‘clean’ CCL will not be contaminated at any time but can minimize the risks and optimize the flow of patients in the CCL, mainly of those at “low risk for exposure”. It is advisable to consult with the hospital engineering about the possibility of having “negative air pressure” procedure rooms. Understanding the air conditioning system is important, because one single procedure might expose other hospital areas to viral contamination. 50 5.8.1. Measures of management control. Suppliers, visitors, observers, research coordinators and any nonessential individual for the CCL operation should refrain from entering the CCL during the pandemic. 55 5.8.2. Approaching the patient. It is worth noting the importance of assessing the risk of SARS-CoV-2 infection before submitting the patient to the interventional procedure. Organization is recommended to minimize the waiting times in the hospital common areas before and after the procedure. 7 All patients should be asked about respiratory symptoms, fever or close contact with suspected/positive cases before entering the CCL room, in addition to undergoing temperature check. 55 • Approach to patients without confirmed SAR-CoV-2 infection: Given the current situation and the likelihood of treating asymptomatic or undiagnosed patients, careful protective measures are recommended. Patients should wear surgical mask before arrival to the room. The interventional cardiologist should adopt safety measures that include proper hand hygiene and the use of sterile and water-resistant gown, sterile gloves, goggles, hair covers, and surgical mask. Technologists, nurses and circulating technicians should use goggles, gloves, hair covers, and surgical mask. 55 • Approach to suspected or confirmed COVID-19 patients: Procedures involving airway and/or esophageal manipulation should be considered of high risk. Only essential personnel should be granted access to the CCL room, whose doors should remain closed all time. Avoid exiting the room with contaminated equipment (gown, gloves, mask) to get material (stents, catheters). Ideally the material used in the procedure should remain outside the room. A circulating technician will remain outside the room exclusively providing the material necessary for the procedure to another circulating technician remaining exclusively inside the room. Medications should be prepared before patient’s arrival to the room. The patient should wear a surgical mask, which acts as a barrier to secretions. The staff responsible for moving the COVID-19 patient from the litter to the CCL table should wear PPE, including water-resistant gown, hair covers, gloves covering the wrists, eye protection, and FFP2/N95 mask.56 At the end of transfer, the PPE should be removed as indicated in the following topic, noting that the mask should never be removed inside the CCL room. 55 5.8.3. Putting on PPE: The interventional cardiologist should perform hand hygiene with soap and water, wear a reinforced water-resistant gown (if not impermeable, a plastic gown needs to be added), two pairs of gloves, protective lead goggles or conventional eye glasses, face shield, and high- efficiency filter mask of the FFP2/N95 type. 56 Technologists, nurses and circulating technicians should use gloves, hair cover, water-resistant gown and FFP2/N95 mask. A surgical mask should be put on over the FFP2/N95 mask. Closed shoes are recommended. 56 121