How to Perform Echocardiography Examination During COVID-19 Pandemic: Full or Targeted Examination?

26 April 2020

Written by: M. Arif Nugroho, MD, FIHA

Up to 16 April 2020, there have been 5,516 officially reported confirmed cases of 2019 novel coronavirus (COVID-19) infection in Indonesia. Circulatory dysfunction is considered to have a late onset in severe cases of COVID-19 pneumonia, which is often ignored in clinical treatment. The main causes of acute respiratory failure and subsequent circulatory dysfunction include the rapid progress of lung injury, fluid overload, lung consolidation, and mechanical ventilation for hypoxemia. Most injuries are related to fluid overload, acute lung injury, and long-term hypoxia. Echocardiographic is an important part of critical ultrasonography, which helps to quickly identify the hemodynamic status.1

If transthoracic echocardiography (TTE) is required to change patient management, we recommend a focused cardiac ultrasound study (FoCUS) but should also be comprehensive enough to avoid the need to return for additional images.2,3 Each study should be tailored to the indication and planned in advance, after review of images from past exams and other imaging modalities. The aim is to reduce the time of exposure with the patient and to decrease the risk of contamination.  Hand-held or smaller laptop-based echocardiogram may have an advantage as they are easier to cover, clean, and disinfect than larger machines with higher capability. It is also depends on the capabilities of echo machines used, images practitioners can often be saved to allow remote interpretive assistance from more experienced echocardiography’s consultant. Archiving these images for review should help to focus future imaging studies and provide comparisons of cardiac structure and function over time. In some cases, review of these images by a consulting cardiovascular specialist may obviate the need for an echocardiogram (and therefore reduce staff exposure), as pertinent clinical questions will be answered (e.g. etiology of hypotension). In other cases, they will indicate the need for more advanced imaging (e.g. wall motion and quantitative valvular assessment). Therefore, these images should be saved and archived whenever possible.2,3

At a minimum, such a focused echocardiographic study in patients with verified or suspected COVID-19 should include the following:2

1. Left ventricle: systolic global function (ejection fraction), signs of regional wall motion dysfunction, end-diastolic cavity dimension.

2. Right ventricle: global function [right ventricular fractional area change (RVFAC) or tricuspid annular plane systolic excursion (TAPSE)], end-diastolic cavity dimension, tricuspid regurgitation pressure gradient (TRP) (if possible).

3. Valves: gross signs of valvar disease, but only in cases of critical clinical importance should an in-depth

4. Pericardium: Thickening or Effusion and signs of tamponade

The protocol of echocardiography examination in nCoV pneumonia

Echocardiography can help to quickly identify the circulatory status of COVID-19 pneumonia patients and guide hemodynamic management. Five basic views of echocardiography (apical four chamber view, parasternal long axis view, parasternal short axis view, subxiphoid four chamber view, subxiphoid inferior vena cava (IVC) long and short axis view) should be measured, which help to quickly understand the patient’s volume status, cardiac function, and organ perfusion and help to develop hemodynamic management plans. It is suggested to measure the diameter of IVC, EF, velocity-time integral of the left ventricular outflow during continuous and dynamic evaluation of patients’ volume state and fluid responsiveness, left ventricular systolic function, and left ventricular output effect. If necessary, hemodynamic management can follow the “5P” principle, i.e., lower central venous pressure, optimized pulse/heart rate, appropriate pump function and blood pressure, and organ perfusion as the final goal. 1

Text Box: American Society of Echocardiography recommend due to echocardiographic protocols: 
•	Echocardiographic exams be planned ahead, based on indications, clinical information, laboratory data and other imaging findings to allow for a focused sequence of images that help with management decisions. 
•	The use of ultrasound enhancing agents should be considered prior to the exam to avoid the need to prolong scan time while awaiting preparation of the agent. 
•	Scan times should be minimized by excluding students or novice practitioners from performing imaging. 
•	Imaging team should ensure rapid review and reporting of key findings in the patient’s record and communicating them with the primary care team.


M. Arif Nugroho, MD, FIHA serves as lecturer and cardiologist at Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi General Hospital Semarang


1. Peng, QY.,Wang, XT., Zhang LN., Chinese Critical Care Ultrasound Study Group (CCUSG). Using echocardiography to guide the treatment of novel coronavirus pneumonia. Critical Care. 2020;24: 143.

2. Skulstad, H., Cosyns, B., Popescu, B. A., Galderisi, M., Salvo, G. D., Donal, E., Petersen, S., Gimelli, A., Haugaa, K. H., Muraru, D., Almeida, A. G., Schulz-Menger, J., Dweck, M. R., Pontone, G., Sade, L. E., Gerber, B., Maurovich-Horvat, P., Bharuca, T., Cameli, M., Magne, J., Westwood, M., Maurer, G. & Edvardsen, T. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging. 2020;0: 1-7.

3. Kirkpatrick, J. N. Mitchell, C. Taub, C. Kort, S. Hung, J. Swaminathan, M. 2020. ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak. [Online]. American Society of Echocardiography. Available:

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