key: cord-263244-dv2baj6j authors: Farooqi, Kanwal M.; Ghoshhajra, Brian B.; Shah, Amee M.; Chelliah, Anjali; Einstein, Andrew J.; Hlavacek, Anthony; Han, B. Kelly title: Recommendations for Risk Stratified Use of Cardiac Computed Tomography for Congenital Heart Disease During the COVID-19 Pandemic date: 2020-06-09 journal: J Cardiovasc Comput Tomogr DOI: 10.1016/j.jcct.2020.06.003 sha: doc_id: 263244 cord_uid: dv2baj6j The impact of the coronavirus disease (COVID-19) pandemic in the United States and around the world has required significant changes to medical practice. Amidst the rapidly evolving public health emergency, hospital centers have been required to postpone elective procedures, preserve personal protective equipment (PPE), practice social distancing and limit staff exposures. Patients with congenital heart disease (CHD) often need urgent evaluation, most commonly for preprocedural evaluation. We have stratified the most common indications for cardiac computed tomography (CCT) imaging in patients with CHD to help guide care for these patients during the COVID-19 pandemic including considerations for reopening. Cardiac computed tomography (CCT) is used to define cardiac anatomy in patients with known or suspected congenital heart disease (CHD) primarily to determine optimal timing of surgical or catheter based intervention, and to guide medical management [1] . During the COVID-19 pandemic, elective diagnostic testing has been deferred for many patients. The use of CCT in CHD patients requires stratification to protect patients and staff, optimization of use of personal protective equipment (PPE) [2] and minimizing risk of adverse outcome from deferred testing. The use of CCT amidst the COVID-19 pandemic for adult cardiac indications is outlined in recently published guidelines from the Society of Computed Tomography (SCCT) [3] . These recommendations have limited applicability in the CHD population, but should be followed for adult CHD (ACHD) patients who may require CCT to assess for coronary artery disease in the setting of symptomatic COVID-19 infection [4] . Cases of a multisystem inflammatory syndrome resulting from COVID-19 infection with similarities to Kawasaki disease are recently being identified in children, but the degree of coronary involvement and use of CCT in this setting is not yet well defined [5] . This brief report outlines a strategy for prioritizing of CCT in the CHD population during the current COVID-19 pandemic when diagnostic capacity remains limited. Based on current knowledge, newborns with critical CHD needing CCT have a low likelihood of active COVID-19 infection. Many hospital centers have maternal testing at the time of admission for delivery and vertical transmission of maternal infection to the fetus in utero is considered to be rare [6, 7] . Nevertheless, a robust screening process for COVID -19 must be in place for CHD patients of any age presenting for CCT. Asymptomatic infection is common in young patients and recommendations are made with staff safety considered paramount [8] . Preprocedure and day of procedure screening for illness should be implemented for all patients and accompanying adults, which will vary by institution. Depending on the local prevalence and availability of testing, strong consideration should be given to pre-procedural COVID-19 testing as governed by institutional and regional infectious disease specialists. If testing capacity is limited, cases requiring anesthesia should be prioritized given the potential for aerosolization with airway support. Appropriate use of PPE is vital in minimizing the risk of exposure to the imaging staff. Social distancing should be maintained in the waiting room and imaging suite, and mask utilization may be used for asymptomatic patients and accompanying adults when available, according to CDC guidelines. Appropriate time should be allotted between scans to allow for sanitization of the scanner. These processes should remain in place as long as there is community spread of infection. Only cases that can be safely postponed 4-6 months without adverse effect are considered elective. Optimally, the heart team would determine urgency of imaging for complex CHD patients as outlined. Institutional radiation dose optimization and CHD scan protocols should be maintained during the pandemic [9] [4] Scenarios in which the clinical team feels an examination is indicated should be expedited on a case by case basis. Ensuring safety of staff and patients is of utmost importance when planning for reintroduction of nonurgent cardiovascular services. The impact of delays in treatment due to deferred CHD cardiac procedures during this pandemic is undefined. Young patients with CHD undergo rapid somatic growth which changes the urgency of evaluation over a relatively short interval. Active and ongoing triage of CHD patients with delayed testing is essential. A change in clinical status may affect the urgency of evaluation. The leaders of several North American cardiovascular professional societies recently published guidance for the reintroduction of cardiovascular services [10] . Recommendations are applicable to CHD CCT imaging and include maximizing benefits to those undergoing CCT, weighing the benefit of CCT with the risk of potential for further COVID-19 spread, and consistency in the availability of such services to patients regardless of factors that may impede their accessibility such as social class or ethnicity. Urgent indications to perform CCT for patients with CHD often arise in the setting of a preprocedural evaluation. We have summarized the most common indications in the setting the of the COVID-19 pandemic. Since asymptomatic infection is common in young patients, a robust screening process and optimal use of PPE is needed to protect imaging staff. Recommendations are based on our current understanding of the pandemic, which is changing rapidly. Updated information should inform change in practice as it becomes available. Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT): Endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI) COVID-19: Crisis Management in Congenital Heart Surgery Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography amidst the COVID-19 pandemic Endorsed by the American College of Cardiology AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines COVID-19 and Kawasaki Disease: Novel Virus and Novel Case Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals SARS-CoV-2 Infection in Children Radiation Safety in Children With Congenital and Acquired Heart Disease: A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership We would like to acknowledge Dr. Khurram Nasir, Dr. Andrew Choi and Dr. Ronald Blankstein's support in developing this document. This work was supported in part by the Rachel Cooper Innovative Technologies Fund (KF), the Colin Molloy Award (KF). been deferred for many patients. The use of cardiac computed tomography (CCT) in congenital heart disease (CHD) patients requires stratification to protect patients and staff, optimize use of personal protective equipment and minimize risk of adverse outcome from deferred testing. This brief report outlines a strategy for prioritizing of CCT in the CHD population during the current COVID-19 pandemic when diagnostic capacity remains limited.