IJCS | Volume 33, Nº3, May / June 2020

290 All CCL personnel should wear PPE, including FFP2/N95 respirators, goggles, full face shields, disposable caps, gowns, surgical gloves, and shoe covers, during the entire procedure, because of the potential for those patients’ clinical deterioration and the consequent risk that comes with intubation, aspiration and cardiopulmonary resuscitation. In addition, CCL staff should be well educated in the proper donning and doffing of PPE because of the high likelihood of contamination involved in the process. 3-5 It is worth noting that myocardial injury has been reported in 7% of the patients with COVID-19 and might correspond to type 2 myocardial infarction or myocarditis. 11 Thus, no effort should be spared in reaching the differential diagnosis before the procedure with the aid of imaging tests, such as point-of-care echocardiography . In addition, it is worth emphasizing that percutaneous coronary intervention should only be performed to the culprit vessel, unless a nonculprit lesion is deemed unstable or in the presence of multiple culprit lesions. 12 Post-procedure safety measures During the pandemic, in anticipation of a surge in hospitalization required for COVID-19 infected patients and because not only most inpatient beds will be made available for COVID-19 treatment, but also to avoid additional contamination, hospital discharge will occur earlier for stable patients who might be followed up via telemedicine. 12 Within the CCL, all nonessential equipment should be moved out of the procedure room or covered with clear drapes before patient’s arrival to the room, and the same applies to the control and post-procedure recovery rooms. After a procedure in a patient with COVID-19, thorough terminal disinfection can be performed with ultraviolet light. 12 The standard positive pressure ventilation system of the CCL consists of an air-handling unit that distributes conditioned air to different functional units, including the procedure, post-procedure, and control rooms. Positive pressure with adequate air changes can rapidly eliminate the virus from the environment; in  addition the risk of cross-contamination from airborne infections has been shown to be low if the personnel is protected with appropriate PPE. 9 The positive pressure ventilation system should be extended to the rooms associated with the procedure. It isworthnoting that the inflammatory state of patients with COVID-19 often determines a hypercoagulable condition that requires additional use of heparin. 11 Figure 1 shows the safety recommendations for CCL procedures during the COVID-19 pandemic. Those written in bold letters should receive special attention during the COVID-19 pandemic. Safety andprotectivemeasures for healthcareworkers During the COVID-19 pandemic, all material used for invasive procedures, including the equipment for anesthesia, orotracheal intubation and mechanical ventilation, in addition to PPEs, should undergo a daily check and be readily available for easy and rapid use to minimize the work and burnout of healthcare professionals. 13 The PPE should be removedpreferably in an anteroom. If no anteroom is available, doffing of PPE should be done inside the procedure room, at the end of the procedure and after the patient has been transferred away, except for the PPE for respiratory protection, which must be removed outside the procedure room. 13 Post-procedure visits should be performed by the lowest number possible of professionals; moreover, discussions about additional management should be converted to an online or telephone format, and the same applies to morning CCL rounds. 12-14 Most sanitizers contain alcohol at different concentrations and are used for cleaning and disinfecting high-touch surfaces (floor, walls, ceiling, and countertops), a precaution that is important during the COVID-19 pandemic. SARS-CoV-2, a single-strand RNA virus, is sensitive to ultraviolet radiation and heat, being inactivated by lipid solvents, such as ether (75%), ethanol, sanitizers containing chlorine, peroxyacetic acid and chloroform, except for chlorhexidine. 15 Terminal disinfection of the procedure room at the end of each procedure is highly recommended during the COVID-19 pandemic. Disposable PPE, sheets, fabric, and sponges contaminatedwith blood should be placed into a waste containermarkedwith the biological hazard symbol and disposed into a waste bin labeled as ‘COVID-19’. 10 Figure 2 shows the general safety items for CCL procedures. Those written in bold letters should receive special attention during the COVID-19 pandemic. Figure 3 shows the steps for putting on and removing PPE for CCL procedures during the COVID-19 pandemic. Mariano et al. Covid-19 and safety in the cath lab Int J Cardiovasc Sci. 2020; 33(3):288-294 Viewpoint