Post COVID-19 guidance | TTE

As we pass through the peak of the pandemic, non COVID-19 clinical activity is tentatively returning. Alongside cancer services, cardiology activity has been recognised as a NHS priority. 

Many of us are keen to return to normality, anxious that several patients with serious modifiable pathologies currently remain in a holding pattern in the community. However, given that COVID-19 continues to be endemic with the probability of a second wave of infections later in the year, it will not be possible to return to the previous model of delivery of care for the foreseeable future.

This interim guidance provides a framework for tailoring departmental echo activity at this time. The ideas presented focus predominantly on transthoracic echo (TTE); whilst specific details for transoesophageal echo (TOE) and stress echo (SE) services are also discussed. Particular thanks is given to Wendy Gamlin, Expert Cardiac Physiologist from Manchester University NHS Foundation Trust, for her extensive input.

Who can/should attend for an outpatient echo?

This will need to be decided in line with the changes in government restrictions and any local initiatives but is likely to begin with more urgent referrals and younger patient groups.  A list of conditions which have been identified as a “higher risk for COVID-19” can be found in Appendix One. A senior member of the echo team should identify potential patients. If the patient has referrals for multiple tests these should be performed on the same day to avoid repeat attendances.  

Booking procedure

A member of the echo team should contact the patient by telephone to discuss their planned attendance. A structured questionnaire should be followed, for example:

Question 1: Have you or anyone you live with had a letter from the NHS informing you that you are at higher risk of COVID-19 and should not leave your home?

If the patient answers Yes, whilst this group of patients remain vulnerable, current advice is that they may leave their home if they wish, as long as they are able to maintain strict social distancing. Cognisant of this advice, the patient should be invited to attend for their procedure in the knowledge that PPE and other strict infection control measures will be in place. If they are concerned about worsening symptoms, they should consult NHS 111 or their GP for advice.

If the patient answers No, proceed to question 2.

Question 2: Have you or anyone you live with had a persistent cough, temperature or tested positive for COVID-19 within the last 14 days?

If the patient answers Yes, they cannot be appointed at this time. They should be advised to follow the government guidance regarding self-isolation. They should be asked to re-contact the department following this period of isolation.

If the patient answers No, proceed to question 3,

Question 3: Are you able to get yourself to the department for an appointment?

If the patient answers No, It may be necessary to wait until further relaxation of lockdown measures to proceed with their appointment.

If the patient answers Yes, offer them the next available appointment and inform them that only they will be able to attend the department. If applicable, advise the patient to attend via the non-COVID entrance to the hospital/department. Before ending the call inform them that if they or a person they live with develop symptoms between now and the appointment time they must phone the department to re-schedule.

Appointment schedule

Echo appointments should be scheduled to allow sufficient time to clean all equipment and surfaces appropriately after each patient and the donning/doffing of personal protective equipment (PPE).

Day of the appointment

The patient should be met at the door by a member of the team who should be wearing appropriate PPE. The patient’s temperature should be recorded:

If it is equal to or greater than 37.8°C:

They should be advised to return home and consult NHS 111 if concerned.

If it is less than 37.8°C:

The patient should be asked “Have you or anyone you live with had a persistent cough, temperature or tested positive for COVID-19 within the last 14 days?”

If the patient answers Yes, they should be advised to return home, self-isolate as per guidelines and consult NHS 111 if concerned.

If the patient answers No, the patient should apply alcohol gel to their hands and then put on a surgical mask and gloves prior to entering the department. Seats in the waiting area should maintain social distancing and be cleaned down with disinfectant wipes after the patient has been called in for their appointment.

The echo appointment

The aim should be to minimise the time the patient spends waiting in the department. If the patient is early and the physiologist is ready for them, they should be taken through for the echo immediately rather than delaying until their appointment time. The physiologist should wear appropriate PPE to collect the patient from the waiting room. The patient should be asked if they know their height and weight to avoid any unnecessary repeat measurements.

As focused a study as the referral allows should be undertaken, accepting that a patient with no previous study will need to have a full dataset obtained.

At the end of the study the patient should be shown where to dispose of their PPE before leaving the department. The physiologist’s PPE should then be removed appropriately, and the room cleaned immediately in preparation for the next appointment.

The echo report

In addition to a normal echo report it is helpful to record any change in the patient symptoms or clinical status (e.g. burden of peripheral oedema). This will allow the referring clinician to minimise any unnecessary repeat hospital attendance following the scan. 

Transoesophageal echo and stress echo

In addition to the TTE workflow guidance outlined above, specific considerations apply to TOE and SE services.

Thorough scrutiny of all referrals by the performing clinician is suggested, with scanning only recommended where the information obtained is likely to significantly alter the patient’s clinical management. To assist this process, discussion with surgical or interventional cardiology colleagues is advised prior to all relevant cases and consideration should be given to alternative forms of cardiac imaging where local services allow. For example:

  • Where echo windows permit, TTE alone should be used to identify patients with native valve infective endocarditis that require early surgical intervention. The subsequent management of patients with uncomplicated endocarditis may be undertaken using repeat TTE scanning rather than TOE; with the duration of antibiotic therapy decided in conjunction with microbiology colleagues.
  • Dependent on local availability, the evaluation of coronary artery disease may be undertaken by stress perfusion cardiac MRI, CT coronary angiography or nuclear medicine imaging. If SE is undertaken it should be noted that, of the two modalities available, exercise potentially generates more aerosolized particulate matter and so dobutamine stress may be preferable.
  • Assessment of the severity of borderline aortic stenosis cases may be sufficiently achieved using CT aortic valve calcium scoring instead of low-dose dobutamine SE; provided that flow (“contractile”) reserve data is not required.
  • It may be possible to undertake peri-procedural imaging guidance with intra-cardiac echocardiography instead of TOE.

All members of the team present during these scans should wear PPE as required for an aerosol generating procedure.

Appendix 1

People at very high risk – these patients will have had a letter informing them they should be shielding – i.e. not leaving their homes for any reason:

  • have had an organ transplant
  • are having chemotherapy or antibody treatment for cancer, including immunotherapy
  • are having an intense course of radiotherapy for lung cancer
  • have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
  • have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
  • have been told by a doctor that they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
  • are taking medicine that render them much more likely to get infections (such as high doses of steroids)
  • have a serious heart condition and are pregnant

People at high risk – should only leave their homes for essential reasons:

  • are 70 or older
  • are pregnant
  • have a learning disability
  • have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)
  • have heart disease (such as heart failure)
  • have high blood pressure (hypertension)
  • have diabetes
  • have chronic kidney disease
  • have liver disease (such as hepatitis)
  • have a condition affecting your brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis, or cerebral palsy)
  • have a problem with their spleen or have had their spleen removed
  • are taking medicine that can partially affect the immune system (such as low doses of steroids)
  • are very obese (a BMI of 40 or above)

1. NHS. (2020). Who's at higher risk from coronavirus. Available at: [Accessed 12 May 2020]


CV-19 is a complex and heterogenous entity and our understanding of it is ever evolving. The short list of CV-19 symptoms referred to in the above guidance has been taken from the NHS webpage. However, it is clear that several patients with CV-19 experience a more varied and myriad set of symptoms; an important clinical feature that is encapsulated neatly in World Health Organisation guidance.

The very nature of producing guidance that is easy to follow results in compromises being made regarding the sensitivity and specificity of the symptoms questioned. Therefore, whilst it is worthwhile enquiring whether a patient has experienced the less common CV-19 symptoms, this needs to be done with the knowledge that a significant cross-over of these symptoms exists with several common, self-limiting, medical conditions (e.g. seasonal allergic rhinitis). Accordingly, each case will need to be reviewed on its own merits and, as we are more than used to in echocardiography, discussion between colleagues regarding uncertain/’grey’ cases remains vital.