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 15 – Recommendations of transthoracic echocardiography in mitral stenosis Recommendation Class of recommendation Level of evidence Establish diagnosis of patients with signs and symptoms of MS I B Quantification of severity (PHT, gradients, valve area and pulmonary artery pressure) I B Assessment of concomitant valve lesions I B Determination of score for valvotomy by balloon catheter. Block Wilkins: thickening, mobility, subvalvar and calcification I B Reassessment of stable MS with area < 1 cm² each year Reassessment of stable MS with area between 1 and 1.5 cm² every 2 years Reassessment of stable MS with area > 1.5 cm² in 3 to 5 years Immediate reassessment with change of symptoms I B Follow-up of balloon catheter valvuloplasty after dilatation I B Assessment of hemodynamic alterations and adaptation during pregnancy I B MS: mitral stenosis; PHT: pressure half-time. Table 16 – Recommendations of transesophageal echocardiography in mitral stenosis Recommendation Class of recommendation Level of evidence Inconclusive transthoracic echocardiography I B Assessment of thrombus preceding balloon catheter valvuloplasty I B Assessment of the degree of mitral regurgitation preceding balloon catheter valvuloplasty (when there is doubt about transthoracic) I B Table 17 – Recommendations of stress echocardiography in mitral stenosis Recommendation Class of recommendation Level of evidence Discordance between symptoms and valvar area/gradient (mitral area > 1.5 cm²) I C Assessment of asymptomatic patients with area < 1 cm² IIa C Assessment of asymptomatic patients with an area between 1 and 1.5 cm² in pregnancy or major surgery planning IIb C (valvular calcification), etiology (degenerative, congenital or rheumatic), LV exit path (diameter and geometry, mainly 3D) and greater accuracy in the calculation of valvular area, either by continuity equation or by direct planimetry. 147,150 The absence of significant calcification should alert to the possibility of sub- or supravalvar obstruction. In good- quality images, 3D TTE also allows for a more accurate LVEF assessment and a calculation of ejection volume (aortic transvalvular flow) by subtraction of final diastolic and systolic volumes, without the need to use LV exit pathway measurement and Doppler. This calculation, however, should be analyzed along with the other parameters, once it may also underestimate aortic transvalvular flow. 147,150 If the calculation of the valve area is made during hypertension (blood pressure ≥ 140 x 90 mmHg), it should be repeated after blood pressure control because it may underestimate the transvalvar flow. Reduction in LV systolic function by GLS measurement, with no other explanation, in the presence of preserved LVEF, favors the diagnosis of severe AVS with low paradoxical gradient. Stress echocardiography with low dose of dobutamine, with calculation of the projected area of ​the valve, if necessary, 144,147 should be performed if there is marked aortic stenosis with low-flow/low gradient and left ventricular dysfunction (stage D2) to distinguish truly marked stenosis from pseudostenosis and to evaluate the contractile reserve (Table 19). Echocardiography under physical stress is recommended to unmask symptoms or to provide prognostic information on moderate or marked asymptomatic AVS with preserved LVEF (stages B or C) (Table 19). An increase in the mean pressure gradient (> 18 to 20 mmHg), the absence of contractile reserve and the increase of pulmonary artery systolic pressure (PASP) > 60 mmHg during exercise are parameters of worse prognosis and require follow-up at shorter intervals. 144 Stress echocardiography may also be useful in low-flow/low paradoxical gradient (with preserved LVEF), asymptomatic or with mild or doubtful symptoms, to confirm the severity of AVS using the same criteria. 144 In suboptimal images, the 153