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 12 – Recommendations of transesophageal echocardiography in mitral regurgitation Recommendation Class of recommendation Level of evidence Intraoperative assessment to define the mechanism and to assist in valve repair I C Unsatisfactory TTE for determination of severity and/or insufficiency mechanism, or for the assessment of LV function I B Asymptomatic patients with severe MR to assess the possibility of valve repair IIa C 3D TEE to assess preoperative anatomy and left ventricular function IIb B Assessment of patients with slight MR III C TTE: transthoracic echocardiography; LV: left ventricle; MI: mitral regurgitation; TEE: transesophageal echocardiography. Table 13 – Recommendations of echocardiography in patients with mitral valve prolapse Recommendation Class of recommendation Level of evidence Diagnosis, anatomical and functional evaluation of patients with physical signs of MVP I C Confirmation of MVP in patients with previous diagnosis, but without clinical evidence to support it I C Risk stratification in patients with clinic features or diagnosis of MVP IIa C Exclusion of MVP in first-degree relatives of patients with myxomatous valve disease IIb C Exclusion of MVP in patients with no suggestive physical signs or family history III C Periodic echocardiographies in patients with MVP without insufficiency or with slight insufficiency, without alterations of symptoms or clinical signs III C MVP: mitral valve prolapse. Table 14 – Elements of echocardiographic evaluation of mitral stenosis Parameter Description Valve anatomy Presence of dome, commissural fusion Doppler PHT value Two-dimensional or three- dimensional Planimetry of the mitral valve area Left atrium Indexed volume Pulmonary artery pressure Assessment of tricuspid or pulmonary insufficiency PHT: pressure half-time. from the disproportion between the valve area and the patient’s body size, or the lack of complacency of the valve orifice (which should increase during exercise). 144 On a low-dose dobutamine echocardiography, the mean mitral transvalvular gradient should increase above 18 mmHg 145 in order for MS to be considered the cause of the symptoms, while on exercise echocardiography (treadmill), the significant cut-off value is one elevation above 15 mmHg. 138,144 The increase in systolic pressure in the pulmonary artery is considered of clinical value only during the exercise echocardiography and should reach at least 60 mmHg so that pulmonary hypertension is considered secondary to MS. Other less frequent indications of a stress echocardiography may be found in asymptomatic patients with marked stenosis (Table 17). 144 Care should be taken to diagnose associated lesions in MS, whether it is a significant MI (which imposes a limitation on balloon catheter valvuloplasty) or lesions on other heart valves. 3.2.3. Aortic Stenosis TTE is the first-line method (Table 18) for the diagnosis and assessment of the severity of aortic valve stenosis (AVS). 128,146-148 The definition of the moment of surgical or percutaneous intervention depends on the integrated analysis of clinical and echocardiographic parameters (valvular anatomy, Doppler valvular hemodynamics and repercussion on cavity size and pulmonary artery pressure) that allow to classify aortic stenosis into four stages: stage A (risk of AVS); stage B (mild and moderate asymptomatic AVS); stage C (asymptomatic marked AVS), subdivided into C1 (with LVEF ≥ 50%) and C2 (LVEF < 50%); and stage D (classical symptomatic marked AVS). 149 In some AVS subgroups, valve area is reduced in the low gradient and low flow periods, either due to the concomitance of left ventricular dysfunction (LVEF < 50%) or the presence of small and hypertrophied LV, despite preserved LVEF). These subgroups are designated as stage D2 (with decreased LVEF) or D3 (with normal LVEF). 146,147,150 In these discrepancy situations, in which valve area is ≤ 1.0 cm², the gradient is < 40 mmHg and LVEF is preserved (AVS with low paradoxical gradient or with low gradient and normal flow), additional methods such as TEE (3D, if possible), computed tomography or cardiac resonance may be necessary to confirm the severity of AVS. 147 TEE allows a better evaluation of the aortic valve anatomy 152