ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 evaluation of LVEF can be improved by the use of myocardial contrast, to better delineate endocardial borders. 147 The invasive hemodynamic study is restricted to situations in which noninvasive imaging tests are inconclusive. 146,149 The follow-up interval with TTE depends on the stage of the disease and predictors of poor prognosis. Accentuated aortic valve calcification is another predictor of more severe stenosis and worse clinical progression. 151 Marked AVS with low paradoxal gradient has worse prognosis when compared to classical AVS and the remaining AVS subgroups. 150 The paradoxical low gradient and normal flow (LV > 35 mL/m 2 ) seems to have a prognosis similar to that of moderate AVS, but should be accompanied by shorter intervals, particularly if symptomatic. 147 In classical AVS, the maximum velocity ≥ 5m/s 152 and an annual increase in maximum velocity ≥ 0.3cm/s 151 in serial examinations (recorded in the same incidence and with the same quality) are predictors of worse prognosis and of faster progression. 146,147,149 In patients who are candidates for percutaneous implantation of aortic prosthesis for the treatment of AVS, 3D TEE can be used to evaluate the diameter of the ring, but it depends on the operator and image quality and should be used only when there is contraindication to computed tomography. On the other hand, 3D TEE is recommended to monitor the procedure and to evaluate outcomes or complications (Table 20). 148 3.2.4. Aortic Regurgitation Echocardiography is the first-choice method to confirm diagnosis and etiology and to assess the severity and hemodynamic consequences of aortic regurgitation (AR). 133,153 AR can be observed due to primary diseases of the aortic valve (AV) or to abnormalities of the aortic root and ascending aorta. Degeneration of AV and bicuspid aortic valve are the most common etiologies. Other causes include rheumatic fever, fibrosis or infection, alteration of the valvular apparatus support or dilatation of the valve ring. The integrated analysis of clinical and echocardiographic parameters (valve anatomy, aortic root and ascending aortic root diameters, Doppler valvular hemodynamics and repercussions on cavity size and pulmonary artery pressure) allows the classification of AR in four stages: stage A (risk of AR), stage B (mild to moderate asymptomatic AR), stage C [asymptomatic acute AR without (C1) or with dysfunction/dilation of LV (C2)]; and stage D (symptomatic acute AR). 149 In suboptimal images, LVEF measurement may be more accurate with the use of myocardial contrast to delineate the endocardial borders. 133 TEE (with 3D if available), tomography or cardiac resonance may be necessary to better assess the aortic root and ascending aorta (especially in the case of a bicuspid aortic valve), the severity of AR, or the quantification of LV ejection volumes and ejection fraction. 133 The appearance of symptoms in AR drastically changes prognosis. Effortless echocardiography may be indicated to reveal the presence of symptoms or to investigate other causes not related to AR (diastolic dysfunction, pulmonary hypertension or dynamic MI). 144 However, it should not be used to assess severity, once that increased heart rate shortens diastole, limiting quantification. 144 The follow-up interval with TTE depends on the stage of the disease and the presence of aortic dilatation associated with bicuspid aortic valvopathy. 148,154 Recommendations for the use of the various modalities of echocardiography in AR are set out in tables 21 to 24. 3.2.5. Tricuspid Valvulopathy TTE is the first-line method for evaluating tricuspid valve abnormalities (Table 25). 146,148,149 In most cases, tricuspid regurgitation (TR) is secondary to tricuspid ring dilatation and leaflet pull due to distortion and right ventricular remodeling, which occur due to volume or pressure overload caused by diseases of the left side of the heart , pulmonary hypertension, pulmonary valve stenosis, among others. In this context, leaflets are structurally normal. Primary causes of TR are rarer and may be due to infective endocarditis (mainly drug users), rheumatic heart disease, carcinoid syndrome, myxomatous disease, endomyocardial fibrosis, corneal rupture related to endomyocardial biopsy, Ebstein’s anomaly, and congenital dysplasia, among others. 133 Similar to mitral and aortic valve disease, it can be classified into four stages (A to D). 149 A thorough analysis of valvular anatomy by TTE is fundamental for the diagnosis of the etiology and mechanisms involved. It is necessary to measure the diameter of the ring and the use of all indexes of RV systolic size and function. 133 These measures help in decision making regarding the moment of the surgery and in the surgical planning. In situations of doubt regarding the RV, 3D TTE can be used, although it still requires more validation. Cardiac resonance remains the gold standard. 146 In this context, TEE is not recommended due to the anterior location of the RV, which makes it difficult to see through the transesophageal route.148 Significant primary TR requires intervention before RV impairment. 146,149 Secondary TR is usually treated when left side valve disease is corrected. As in the other valvopathies, the echocardiographic follow-up interval depends on the stage of the disease, but the etiology of the disease must also be considered. In the case of secondary TR, it is appropriate to follow the recommendations described for left heart valve dysfunctions. Significant annular dilatation (≥ 40 or > 21 mm/m²) and dilatation or progressive RV dysfunction should alert for earlier follow-up. 133 Tricuspid stenosis (TS) is an uncommon condition that, if present, is frequently associated with TR of rheumatic origin. 146,149 In this case, the presence of associated mitral stenosis is common, which is usually the predominant lesion. Other causes are rare, such as congenital diseases, drugs, Whipple’s disease, endocarditis, and large right atrial tumor. 146 TS diagnosis of is often neglected. Careful analysis of the subvalvular apparatus is essential to predict valve repair. 146 The integration of clinical and echocardiographic parameters related to TS (mean gradient > 5 to 10 mmHg, valve area ≤ 1.0 cm² and mean time of pressure drop ≥ 190 ms) classifies severity in stages C (marked asymptomatic) and D (marked symptomatic). 149 3.2.6. Pulmonary Valvulopathy TTE is the initial recommended method to diagnose and evaluate the severity of pulmonary stenosis (PS) or regurgitation (PR), its etiology and effects on cardiac structure and right ventricular function (class I). 133,149 In addition to assessing the valvular anatomy, investigation of the etiology requires a 154