ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 The evaluation of the coronary reserve flow, as well as the sonographic contrast infusion to highlight the borders and to evaluate the myocardial perfusion , when combined with stress echocardiography, have been shown to increase the accuracy of the diagnosis of graft vascular disease. 55-59 Thus, dobutamine stress echocardiography alone (class IIA, level B) or in association with the evaluation of the flow of coronary reserve and/or with the use of sonographic contrast (class I, level B) may be an adequate noninvasive alternative to routine coronary angiography to assess the presence of cardiac graft vasculopathy, provided that the medical center has good experience with methodologies. In addition to the role of cardiac graft monitoring, intraoperative echocardiography can be used as an alternative to fluoroscopy to guide endomyocardial biopsies, avoiding repeated exposure to X-rays, particularly in children and young women (class I, level B). Whether in transthoracic or transesophageal mode, the echocardiography allows a simultaneous visualization of the soft tissues and the biotope, guaranteeing greater biopsy safety in different regions of the RV with a reduction in the complication rate. 47,60 Furthermore, the use of echocardiography during the procedure allows immediate recognition and management of a possible complication. 2.3.5. Monitoring of Cardiac FunctionDuring Chemotherapy with Cardiotoxic Drugs Current cancer therapy is quite effective in some types of tumors, though it can induce cardiovascular complications. Cardiotoxicity (CT) induced by cancer treatment is recognized as the major cause of morbidity and mortality in cancer survivors. 61 Before starting anti-neoplastic treatment, it is essential to access the risk of CT, 62 taking into consideration: (a) the specific risk of the drug used in chemotherapy, as some of themmay affect the cardiac function (anthracyclines, trastuzumab), while other ones, the vascular function (5-fluoracil, capecitabine), or both (bevacizumab); (b) the use of radiotherapy, as it increases the risk of heart failure when concomitant with anthracyclines, pericardial lesion (constrictive pericarditis) and coronary artery disease; (c) the presence of previous risk factors, such as age > 65 years, female gender, hypertension, diabetes mellitus, coronary artery disease and history of heart failure. All patients receiving potentially cardiotoxic drugs should be periodically monitored for CT signs, which can be classified according to the injury the drug used produces. 63 CT Type I, potentially irreversible, anthracycline-related dose, is dose-dependent, mainly at > 250 to 300 mg/m² (often used in the treatment of breast cancer, lymphoma, leukemia, and sarcoma). It most commonly occurs in the first year of chemotherapy, or even two to three decades after completion of treatment, as progressive systolic dysfunction. It may rarely present as an acute systolic dysfunction, immediately after dosing. Type II CT, which is potentially reversible, mainly related to trastuzumab (used in the treatment of breast cancer in patients with increased HER2 receptor expression), has no relation to the cumulative dose. 63 Such information is the basis for the algorithms of serial left ventricular function monitoring during and after treatment of cancer patients, published by the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). 3 The most historically used parameter is LVEF, calculated by TTE using the Simpson biplanar 2D method. 4 LVEF values ​between 53 and 73% should be considered normal in the evaluation. The main advantages of 2D TTE in relation to other imaging modalities, such as radioisotope ventriculography and magnetic resonance imaging (MRI), are: greater availability, lower cost, possibility of serial re-evaluations and greater safety (absence of radiation and limitation in patients with renal insufficiency). 3D TTE, used in sequential and comparative MRI evaluations for LVEF assessment, showed reproducibility comparable to MRI and better accuracy than 2D TTE, 64 being more indicated, when available, in the serial evaluation of these patients. 65 The definition of CT due to chemotherapy was defined by the consensus of these two societies 3 as the decrease of LVEF > 10 percentage points to values < 53% and should be confirmed after 2 to 3 weeks of diagnosis by new imaging. This decrease may or may not be accompanied by symptoms of heart failure and may or may not be reversible. One of the major limitations of the use of LVEF for CT diagnosis in the follow-up of these patients is that changes in LVEF occur later. In order to minimize the risk of developing irreversible cardiomyopathy, it is essential to identify early signs of CT, since the administration of cardioprotective medication in this phase may result in an improvement in cardiac function. 66 Thus, the search for a technique that allows subclinical and early detection of CT before LVEF decrease or the onset of clinical symptoms has been an area of intense investigation. In this scenario, the use of GLS gained importance, evaluating myocardial deformation. Such technique has inter- and intraobserver reproducibilities smaller than the LVEF obtained by the 2D TTE, but is limited by the variability of normal values ​according to the brand of the equipment used, age and gender of the patients. 67 Systematic review confirmed the prognostic value of the alterations in GLS for CT, preceding the LVEF decrease obtained by 2D or 3D TTE. 15 The consensus recommends serial GLS evaluation in patients at risk of CT, with subclinical left ventricular dysfunction suggestive of a fall of > 15% of the baseline value, even without LVEF change. 63 The relative decrease between 8 and 15% suggests a more rigorous follow-up. GLS Variation of < 8% is consistent with absence of subclinical dysfunction. 63 Although some studies have drawn attention to changes in diastolic function following chemotherapy,68 there is no current evidence to support such parameters as indicative of CT. 63 A use of biomarkers in the assessment integrated with imaging methods in chemotherapy patients evidenced the importance of troponin I (TnI) with a high negative predictive value in the detection of CT. 69 It is probable that patients who do not evolve with TnI elevation have lower probability of events and perhaps less need for imaging tests in subsequent evaluations. 69,70 There is still no robust scientific evidence based on randomized clinical trials to support the algorithms proposed by the European Society of Oncology 71 and the consensus of EACVI and ASE, 63 in the follow-up of these patients; however, these documents represent current knowledge in the area. The orientation of the EACVI - ASE consensus 63 to the present moment is: a) Initial evaluation of left ventricular function before the start of chemotherapy in patients who will use potentially 143