key: cord-1019888-bsvlo6zx authors: Aggeli, Constantina; Oikonomou, Evangelos; Tousoulis, Dimitris title: A reappraisal of the role of transthoracic ultrasound in the era of COVID-19. Patient evaluation through new windows date: 2020-06-11 journal: Hellenic J Cardiol DOI: 10.1016/j.hjc.2020.06.003 sha: 6c84fb680ddf46e930872e1b05c963aa0074e112 doc_id: 1019888 cord_uid: bsvlo6zx nan The 2019 novel coronavirus disease (COVID-19) is an outbreak of respiratory disease causing severe acute respiratory syndrome [1] . As of May 7, 2020, a total of 3.76 million cases have been confirmed and more than 264.000 deaths have been reported all over the world. Cardiovascular system is the second most affected target of COVID-19, hence early diagnosis of cardiac involvement should guide treatment decisions. SARS-CoV-2 infection act as triggering factor for cardiac events therefore under the current pandemic, COVID-19 should be included in the differential diagnosis even for patients presenting with typical chest pain or other equivalent symptoms for acute cardiac event. Hence availability of diagnostic techniques such as x-ray, transthoracic echocardiography (TTE), chest CT as well as supporting therapeutic devices in hemodynamically unstable patients are of importance. New recommendations have already published by EACVI focused on the use of TTE in the COVID-19 era [2] . ΤΤΕ as a readily available bedside image modality offers precise information and treatment guidance particularly in ICU patients [3, 4] . Beyond the imaging protocol, the study must be performed according to institutional standards to prevent viral transmission and reassure operator safety. As a result, the echocardiographic examination in suspected or confirmed cases of COVID-19 should be focused but comprehensive enough to answer the diagnostic indication and the clinical question. Prolonged examinations should be avoided to minimize infectious risk. To this point the greater the physician's knowledge and experience the sooner and more accurate diagnosis in order to minimize infectious exposure. Regarding the diagnostic approach, the use of pocket devices seems to be feasible preventing viral transmission. It is also important to balance the benefits to the examined patient with the potential risks for other patients or the staff (Figure 1) . Identification of COVID-19 cardiovascular complications by cardiologists should be considered challenging. Myocarditis, acute myocardial infarction mainly type II, stress cardiomyopathy are common complications, while pericarditis is reported rarely. There are several putative mechanisms of cardiac injury in COVID-19 patients such as ACE2-mediated direct damage, hypoxia-induced myocardial injury, cardiac microvascular damage and systemic inflammatory response syndrome. One step further, it is known that normally, lung parenchyma is not visible beyond the pleura due to the presence of gas [5] [6] [7] . Normal lung aeration is defined as the presence of A lines and/or