ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 cardiac cavities and dysfunction of both ventricles, in addition to allowing the classification of regurgitation into primary (due to valve lesions) or secondary (caused by changes in LV geometry). The 3D echocardiography is more accurate in volumetric measurements and left ventricular function; it can be useful in the evaluation of RV 4 and allows better visualization of the valve apparatus and planning of interventions. 12,133 The evaluation of the regurgitation degree can be made by the integrated approach of multiple qualitative and quantitative parameters: cavity dilations, pulmonary artery pressure, mitral inflow velocity, pulmonary vein flow pattern, mitral regurgitation density and duration analysis, calculus of the jet area or regurgitant volume, vena contracta measurement and regurgitant orifice measurement (flow convergence method, or proximal isovelocity surface area – PISA). 133 Challenging situations for echocardiography are the presence of multiple and/ or eccentric jets, cardiac arrhythmias and acute MR. In these cases, special emphasis should be given to integrated analysis relating anatomical and hemodynamic parameters. The improvement of quantitative measures, such as PISA and vena contracta , through the 3D echocardiography, can aid in the evaluation of eccentric reflux. 132,134 Another important point is the measurement of left ventricular function, especially in asymptomatic patients, which can be overestimated by LVEF measurement, with implications for deciding the best time for intervention and for postoperative outcomes. Recently, measurement of myocardial deformation (strain) has been studied to more sensitively identify ventricular dysfunction, but despite good prospects, it still requires more studies and standardization. 131,135,136 TEE, whether 2D or 3D, is indicated for evaluation of the regurgitation mechanism in the care of inappropriate transthoracic images or in discrepancies between echocardiographic and clinical parameters. 4,133 The general recommendations for the use of the various modalities of echocardiography in MR are contained in tables 11, 12 and 13. 3.2.2. Mitral Stenosis The diagnosis of mitral stenosis (MS) using echocardiography makes it possible to define its probable etiology as a consequence of a wide evaluation of the valve anatomy. 137 The hemodynamic characterization of the gradients and valvular area, together with the description of thickening, leaflet mobility, subvalvar involvement and degree of calcification of the commissures, determines the progression stage of the disease and defines the most appropriate type of treatment when the disease is symptomatic. The joint interpretation of the echocardiography and the clinical symptoms determines the indication of surgical intervention or balloon catheter valvuloplasty. 137 Recently, MS has been grouped into four distinct categories, based on anatomy, Doppler evaluation, presence of pulmonary hypertension, repercussions on LA, and symptoms: stage A (patients at risk for MS); stages B and C (asymptomatic patients, but with hemodynamic changes); and stage D (symptomatic patients with hemodynamic changes). Table 14 describes the parameters that must be included in the echocardiography to make this evaluation complete. 138,139 The use of TTE usually defines the anatomy and severity of the lesion (Table 15), but there are indications for the use of TEE, such as in situations of technically difficult echocardiographic window or 24 hours before balloon catheter valvuloplasty to rule out the presence of thrombi in the LA (Table 16). 138,140,141 3D echocardiography, in the TTE or TEE modalities, has been shown to allow better anatomical analysis and more accuracy in the valvar area calculated by planimetry. 142,143 Physical or pharmacological stress echocardiography (dobutamine) may be used in the discordance between symptoms and resting echocardiography data. 138 Such phenomenon of incompatibility between symptoms and hemodynamic repercussion can result Table 11 – Recommendations of transthoracic and stress echocardiography in mitral regurgitation Recommendation Class of recommendation Level of evidence Initial assessment of severity and MR mechanism I C Periodic assessment of left ventricular dimensions and function in patients with moderate to severe MR without symptom changes I B Patients with MR and modifications of signs or symptoms I B Assessment in the first postoperative month I C Assessment of hemodynamic changes and ventricular adaptation during pregnancy I C Stress echocardiography in asymptomatic patients with severe MI to assess tolerance to physical efforts and hemodynamic changes IIa B Stress echocardiography to assess discrepancy between severity of valve disease and symptoms IIa B Stress echocardiography to evaluate left ventricular reserve IIb B Assessment of ventricular mechanics (strain) for patients with borderline left ventricular function IIb B 3D TTE to assess preoperative anatomy and left ventricular function IIb C Routine assessment of slight MR with LV normal function and dimensions III C MR: mitral regurgitation; TTE: transthoracic echocardiography; LV: left ventricle. 151