Table 1.

Safe Reintroduction of Cardiovascular Procedures and Diagnostic Tests During the COVID-19 Pandemic: Guidance From North American Society Leadership

Response Level (in Collaboration With Public Health Officials)	Level 2 Reintroduction of Some Services	Level 1 Reintroduction of Most Services	Level 0 Regular Services (Ongoing COVID-19 Testing/Surveillance and Monitoring of PPE Availability)
Interventional and Structural Cardiology
STEMI	•COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. •Primary PCI for most patients. Selective pharmacoinvasive therapy as per regional practice. •If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to catheterization laboratory activation or pharmacoinvasive therapy.	•COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. •Primary PCI for most patients. Selective pharmacoinvasive therapy as per regional practice. •If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to catheterization laboratory activation or pharmacoinvasive therapy.	•COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. •Primary PCI for most patients. Selective pharmacoinvasive therapy as per regional practice. •If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to catheterization laboratory activation or pharmacoinvasive therapy.
ACS (NSTEMI/UA)	•NSTEMI (high risk)—invasive strategy (refractory symptoms, hemodynamic instability, significant LV dysfunction, suspected LM or significant proximal epicardial disease, GRACE risk score >140) •Medium-risk NSTEMI—selective invasive strategy •Low-Risk NSTEMI and UA—medical therapy	•NSTEMI (high risk)—invasive strategy (refractory symptoms, hemodynamic instability, significant LV dysfunction, suspected LM or significant proximal epicardial disease, GRACE risk score >140) •Medium-risk NSTEMI—invasive strategy •Low-risk NSTEMI and UA—selective invasive strategy	Routine service for all cases
Elective catheterization laboratory cases	•Outpatients with symptoms AND noninvasive testing suggesting high risk for CV events in the short term	•All outpatients who are clinically considered to be moderate and high risk •Stable cases may still be deferred	Routine service for all cases
TAVR	•Inpatients and outpatients with severe symptomatic aortic stenosis	•Most patients accepted by the heart team •Stable cases may still be deferred	Routine service for all cases
MitraClip	•Inpatients and outpatients with severe symptomatic mitral regurgitation	•Most patients accepted by the heart team •Stable cases may still be deferred	Routine service for all cases
ASD/PFO	•Selective cases	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
LAAC	•Selective cases	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •Pulmonary hypertension •Adult congenital	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Cardiovascular Surgery
Coronary	•Inpatients waiting for surgery •Outpatients with progressive symptoms or LV impairment	•All inpatients waiting for surgery •Majority of outpatients •Stable cases may still be deferred	Routine service for all cases
Valve surgery	•Inpatients waiting for surgery •Outpatients with severe symptomatic valvular disease or LV impairment	•All inpatients waiting for surgery •Majority of outpatients •Stable cases may still be deferred	Routine service for all cases
Other	•Acute aortic dissection •Valvular endocarditis •Heart transplant/VAD •High risk cardiac tumors •Severe symptomatic congenital heart disease	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Electrophysiology
Ablation	•Pre-excited AF •AF with recurrent admissions +/− CHF •Drug refractory VT	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Devices	•PPM for all inpatients and selective high-risk outpatients •Secondary prevention ICD and selective primary prevention ICD. •Device generator elective replacement indicator activated	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •Lead replacement, revision and extraction with infection, or inappropriate shocks •Implantable loop recorder for syncope •Ambulatory monitoring •Cardioversion	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Echocardiography
TTE	•All inpatients •Selective outpatients in which TTE will alter short-term management	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
TEE	•All patients where TEE will alter short-term management. Given potential for false −ve COVID-19 testing, consider aerosol level PPE for possible AGMP.	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Exercise testing with imaging	•Selective cases where exercise testing will alter short-term management •Pharmacological testing preferred over exercise testing	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Cardiac CT
CT coronary angiography	•All inpatients and selective symptomatic outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Structural heart disease	•Pre-procedural structural heart disease planning for all inpatients and selective outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •Pulmonary vein assessment for AF ablation planning •Cardiac masses •Congenital heart disease	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Cardiovascular Magnetic Resonance Imaging
LV/RV assessment	•All inpatients and selective outpatients •Consider alternate imaging modality	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Infiltrative/inflammatory disease	•All inpatients and selective outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Myocardial viability	•All inpatients and selective outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Stress cardiac imaging	•All inpatients and selective outpatients •Consider alternate imaging modality	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •Congenital heart disease •Cardiac masses •Vascular: thoracic aortic disease and pulmonary vein mapping	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Nuclear Cardiac Imaging
Exercise testing with imaging	•All inpatients and selective outpatients •Preference for vasodilator testing over exercise testing	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Myocardial viability	•All inpatients and selective outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •LV assessment •Preoperative organ transplant assessment •Infiltrative diseases	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Heart Failure/Transplant
Cardiopulmonary testing	•All inpatients and selective outpatients	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Endomyocardial biopsy	Selective cases •Transplant surveillance in patients deemed to be at high risk for rejection •Guide treatment in patients with presumed myocarditis	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Right heart catheterization	Selective cases •Facilitate transplant listing or candidacy for mechanical circulatory support •Tailored hemodynamic therapy in cardiogenic shock	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Vascular
Critical limb ischemia	•All inpatients and selective outpatient cases	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
TEVAR/EVAR	•All inpatients and selective outpatient cases	•Majority of cases •Stable cases may still be deferred	Routine service for all cases
Other	Selective cases •Mesenteric ischemia •Symptomatic DVT	•Majority of cases •Stable cases may still be deferred	Routine service for all cases

ACS, acute coronary syndromes; AF, atrial fibrillation; AGMP, aerosol-generating medical procedure; ASD, atrial septal defect; CCT, cardiac computed tomography; CHF, congestive heart failure; COVID-19, coronavirus disease-2019; EVAR, endovascular repair of aortic aneurysm; GRACE, Global Registry of Acute Coronary Events; ICD, implantable cardioverter-defibrillator; LAAC, left atrial appendage closure; LV, left ventricular; LM, left main; MI, myocardial infarction; NSTEMI, non–ST-segment elevation myocardial infarction; PFO, patent foramen ovale; PCI, percutaneous coronary intervention; PPE, personal protective equipment; PPM, permanent pacemaker; STEMI, ST-segment elevation myocardial infarction; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TEVAR, thoracic endovascular aortic repair; TTE, transthoracic echocardiography; UA, unstable angina; VAD, ventricular assist device; VT, ventricular tachycardia; +ve, positive; -ve, negative.