IJCS | Volume 33, Nº3, May / June 2020

291 COVID-19 SAFETY RECOMMENDATIONS FOR CCL PROCEDURES Before the procedure 9 Balance of healthcare personnel exposure against patients’ benefits. 9 Anamnesis: identification, weight, height, indication for exam, comorbidities, risk factors, tolerance to decubitus position, history of allergies, medications being used, previous complementary tests. 9 Signs and symptoms compatible with COVID-19 (fever, cough, dyspnea, myalgia, fatigue, diarrhea, sore throat, chest pain, mental confusion and lethargy). 9 Explanation about the informed written consent and its signature, with emphasis on contamination risks and measures to avoid them. 9 Assess all devices in the CCL procedure room on a daily basis (imaging and telemetry monitors, computers, image acquisition devices, contrast injection pump, anesthesia cart, defibrillator), which should be readily accessible. 9 Nonessential CCL devices should be moved out of the procedure room or covered with clear drapes. After the procedure 9 Assess the possibility of earlier discharge and follow-up via telemedicine. 9 Thorough terminal disinfection after CCL procedures performed in COVID-19 patients. 9 Positive pressure with adequate air changes can rapidly eliminate the virus from the environment and should be extended to rooms associated with the procedure. 9 Surveillance of the puncture site to prevent hematomas. If possible, radial compression bracelet and vascular occlusion devices should be used, but they add cost to the procedure. 9 Educate patients and families on the procedures performed and post- procedural care (household recovery time, puncture site surveillance, medication use, telephone contact made available for digital COVID-19 follow-up ). 9 Provide technical report with description of the procedure, type and amount of contrast used, medications administered, radiological exposure time and dose, complications. During the procedure 9 Use of proper PPE (apron, gown, surgical gloves, goggles, full-face shields, N95 respirators) and training of CCL personnel on putting on and removing PPE. 9 Patient’s positioning with monitoring and re-checking in the presence of all team members (patient’s identification and procedure to be performed, COVID-19 signs and symptoms, medications being used, with an emphasis on antiplatelet agents and sexual stimulants, fasting duration, possible pregnancy). 9 Review of the arterial puncture site. 9 Assessment of contrast type and amount (previous kidney disease, age, patient’s hemodynamic state, estimated glomerular filtration rate). 9 Good communication within the team, with reference and counter-reference, and continuous training in emergency protocols (cardiorespiratory arrest, stroke, anaphylaxis, coronary artery rupture). 9 Talk with the patient for the early approach to complications (analgesia, nauseas). 9 Support the previous differential diagnosis of myocardial injury with imaging techniques, such as point-of-care echocardiography . 9 Percutaneous coronary intervention should only be performed to the culprit vessel. Figure 1 – Safety recommendations for cardiac catheterization laboratory (CCL) procedures during the COVID-19 pandemic. The recommendations written in bold letters apply specifically to the COVID-19 pandemic. 3-5,7,8,10-14, 27,28 A recent case series of 5700 inpatients with COVI‑19 (median age, 63 years; male sex, 60.3%) in the city of New York, United States, has reported a high prevalence of comorbidities, especially cardiovascular ones, as follows: arterial hypertension, 56.6%; coronary artery disease, 11.1%; heart failure, 6.9%; obesity, 41.7%; and diabetes, 33.8%. In- hospital lethality rate was 21%, which increased to 88% among those requiring mechanical ventilation. In addition, the authors have reported that most patients maintained their routine medications, such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. These data reinforce the need to maintain the traditional treatment of patients with heart diseases to avoid decompensation during the pandemic. 29 The challenges presented during the COVID-19 pandemic are huge, not only the approach of patients with cardiovascular diseases, who need to continue their treatments regardless of having or not COVID-19, but also the management of the complex cardiovascular manifestations of SARS-CoV-2 infection, such as myocarditis, Takotsubo syndrome and myocardial injury, which can mimic ST-segment elevation myocardial infarction. In addition, patients usually delay seeking hospital treatment because of fear of contamination. 30,31 During the COVID-19 pandemic, the established strategies, such as primary angioplasty, remain the standard treatment. These strategies should be performed at hospitals that are well equipped for a timely response and that have a team of specialized professionals wearing the aforementioned PPEs. The fibrinolysis-based strategy should be reserved for situations in which primary angioplasty cannot be performed. 31 Although interventional cardiologycertainlyentailsmore engaging topics than safety, extraordinary times call for Mariano et al. Covid-19 and safety in the cath lab Int J Cardiovasc Sci. 2020; 33(3):288-294 Viewpoint