A study conducted in China with 72,314 patients with COVID-19 (44,672 laboratory-confirmed cases, 16,186 suspected cases, and 10,567 clinically diagnosed cases) has reported fever, cough, dyspnea, myalgia, fatigue and diarrhea as the most common symptoms. Other signs and symptoms have been reported, such as sore throat, chest pain, mental confusion, and lethargy. The authors have highlighted that COVID-19 had a benign course in 80% of the cases, and that many patients, although asymptomatic, could carry the virus.⁶ It is worth noting the importance of the differential diagnosis of dyspnea and fatigue, especially when associated with the other symptoms.

During a respiratory pandemic, patients and their families should be informed about the risks of contamination, despite all additional measures taken to minimize them. Because the number of elective procedures will be drastically reduced during that period, the length of hospital stay is predicted to be the minimum necessary for each protocol consensually elaborated.⁷ Moreover, defining a procedure as elective requires clinical judgement, because postponing it might have effects that will increase the likelihood of decompensation and adverse events during the pandemic, such as in high-risk patients with unstable angina. Therefore, the decision about performing a procedure should be individualized and based on the patient’s risk and benefit analysis.⁸

Despite the adoption of measures to reduce exposure, healthcare personnel shortage should be anticipated based on the likelihood of the removal of infected, exposed, at-risk and quarantined healthcare personnel. Particular attention should be given to avoid simultaneous exposure of healthcare professionals sharing the same skill set to prevent simultaneous contamination, especially in teaching institutions where the staff usually act together.⁴ In addition, it is worth emphasizing the importance of reducing as much as possible the circulation in the procedure room to ensure the minimum safety threshold established in CCL procedural protocols.⁴

It is worth noting that patients with suspected or confirmed COVID-19 should ideally undergo procedures at the end of the day or in CCL rooms dedicated to COVID-19, when available, because of the need for terminal disinfection.⁴

Patients already intubated represent a lower risk of contamination to healthcare personnel, because they are on closed-loop ventilation. In 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 procedure and to minimize the contamination of the staff.⁴

Healthcare personnel exposure and benefits to patients should be balanced for all interventional procedures. For example, during a respiratory epidemic, for hemodynamically stable patients with COVID19+ and ST-segment elevation myocardial infarction, fibrinolysis might be an alternative according to some authors;^{6 , 9} however, the length of hospital stay waiting for coronary angioplasty after fibrinolysis should be carefully considered.

It is worth noting that COVID19 is spread via respiratory droplets and contact with surfaces on which the virus can last for long periods, such as cell phone, keyboard, mouse and door handles, thus, the procedure duration should be reduced to a minimum.^{10 , 11} Moreover, patients with suspected or confirmed COVID-19 should be using a face mask upon arrival to the CCL and continue to use it during procedure preparation and the procedure itself.⁴

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

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 is worth noting 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.

Figure 1

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 removed preferably 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 contaminated with blood should be placed into a waste container marked with 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 2

Figure 3 shows the steps for putting on and removing PPE for CCL procedures during the COVID-19 pandemic.

Figure 3

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 cardiology certainly entails more engaging topics than safety, extraordinary times call for extraordinary measures. It is essential to revisit the different aspects of protection for patients and healthcare personnel in the CCL, as well as to tailor them to the COVID-19 scenario.

Health systems around the world have been overwhelmed for months. However, unlike ventilators and wards, healthcare personnel cannot be ‘manufactured’ urgently, mainly highly specialized professionals, such as CCL staff.³²

All activities performed in CCL rooms need to be restructured, and registries should be kept to quantify the effects of COVID-19 on the treatment of patients with cardiovascular diseases. In doing so, we will be able to learn from this pandemic and thereby both add value to this field and contribute to a rapidly growing body of knowledge on COVID-19.