ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 Table 1 – Recommendation of echocardiographies in dilated cardiomyopathies Recommendation Class of recommendation Level of evidence Assessment of patients with suspected dilated cardiomyopathy or heart failure I C Assessment of signs and symptoms suggestive of myocardial dysfunction I C Reassessment of patients with cardiomyopathy known to present worsening of symptoms or to require changes in therapy I C First-degree relatives of patients with dilated cardiomyopathy I B Assessment of candidate patients for cardiac resynchronization therapy with LBBB and QRS duration between 120 and 149 ms IIa C Reassessment of routine in patients with stable dilated cardiomyopathy, without clinical or therapeutic changes III C Chagasic cardiomyopathy Initial evaluation of patients with positive serology for Chagas disease for diagnosis and risk stratification of cardiomyopathy I C Patients with the indeterminate form of Chagas disease who present new electrocardiographic alterations compatible with the development of cardiomyopathy I C Patients who present worsening symptoms of heart failure, syncope, arrhythmic or thromboembolic events I C Routine reassessment of clinically stable patients with no changes in therapy III C LBBB: left bundle branch block. initial systolic volume, analyzed between 3 and 6 months of the implant. 39,44 In case the negative remodeling and/or the clinical improvement of the patient is not met, one possibility is to adjust the pacemaker, guided by TTE, to optimize the atrial and ventricular stimulus intervals. The main correction in this case seems to be adjustment of the atrial and ventricular stimulus intervals, guided by the echocardiography, which allows for retrieval of the results. 45,46 2.3.4. Assessment after Heart Transplantation The echocardiography is the main noninvasive imaging modality as well as the most versatile one in the evaluation and monitoring of patients after cardiac transplantation, providing accurate information on morphology and graft function. From the immediate postoperative period up to the moment of hospital discharge, serial echocardiographic exams are recommended both to identify and monitor surgical complications and early graft dysfunction, whether due to primary or secondary causes (e.g., reperfusion injury, non- responsive pulmonary hypertension (class I, level B). 47,48 In the presence of early graft dysfunction, the echocardiography usually shows an overall reduction in myocardial function (LVEF < 45%), loss of the contractile reserve, increase in RV volume with systolic dysfunction (tricuspid annular plane systolic excursion – TAPSE < 15 mm or RV ejection fraction < 45%). 47 A comprehensive echocardiographic examination (class I, level B) is recommended in the sixth month after cardiac transplantation), which will serve as the baseline for assessing graft morphology and function during sequential and regular follow-up examinations (interval and frequency of exams in figure 1). 47 Quantifications of cardiac chambers size and volumes, RV systolic function, LV diastolic and systolic parameters, and pulmonary arterial pressure should be performed on the sixth month and subsequent echocardiographies. 47 It is recommended that such echocardiographic studies also include advanced methodologies, such as the study of myocardial deformation (strain) and 3D evaluation of the volumes and function of cardiac chambers and tricuspid valve (frequently injured during the endomyocardial biopsy procedure), for providing a more accurate and comprehensive analysis (class I, level B). 47 It should be noted that there is no single isolated echocardiographic parameter that can be reliably used to diagnose acute rejection. 47 However, an echocardiographic study with no change from the baseline study has a high negative predictive value for acute rejection of the graft. On the other hand, if several echocardiographic parameters are abnormal, the probability of acute rejection of the graft increases considerably. 47 When an abnormality is detected, a careful review of the images of the present study and the baseline study (side-by-side) is highly recommended (class I, level B). 47 GLS is an adequate parameter to assist in the subclinical diagnosis of graft dysfunction, regardless of etiology, in addition to an adverse event predictor, when comparing the variations of values occurred during serial evaluations (class IIb, level B). 47,49,50 The association of GLS with endomyocardial biopsy helps to characterize and monitor an episode of acute rejection or global dysfunction. 47 Pericardial effusion should be serially assessed for extent, location and hemodynamic impact (class IIb, level B). In the case of a recently detected pericardial effusion, the hypothesis of acute rejection should be considered, taking into account the patient’s global and clinical echocardiographic evaluation. 47,51 Cardiac graft vascular disease is the main cause of late complication; and the dobutamine stress echocardiography has proven to be a safe and accurate method to identify the affected patients. 47,52-54 142