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 18 – Recommendations of transthoracic echocardiography in aortic valve stenosis Recommendation Class of recommendation Level of evidence Diagnosis and assessment of the severity of AVS in the presence of suspicious murmur or symptoms potentially related to AVS, such as: chest pain, dyspnea, palpitations, syncope, stroke or peripheral embolic event I B Syncope I B History of bicuspid AV in first degree relatives I B Patients with AVS to assess wall thickness, LV size and function I B Reassessment of patients with the AVS diagnosis with change of symptoms or signs I B Suboptimum transthoracic contrast echocardiography (≥ 4 contiguous LV segments not seen), for assessment of LV function and calculation of the ejected volume I B Annual reassessment of asymptomatic patients with marked AVS (maximal velocity ≥ 4 m/s) (stage C1), with reduction of the interval to 6 months if there are predictors of greater severity at rest (AV marked calcification, maximum velocity > 5.5 m/s, increase in maximal velocity ≥ 0.3 m/s/year and low-flow/low paradoxical gradient) or effort echocardiography* I B Reassessment every 1 to 2 years of asymptomatic patients with moderate AVS (maximal velocity 3 to 3.9 m/s) (stage B), with reduction of the interval to 1 year if there are predictors of greater severity on echocardiography at rest or effort echocardiography* I B Reassessment of asymptomatic patients with discrete AVS (maximal velocity 2 to 2.9 m/s) (stage B), every 3 to 5 years, with reduction for 1 year in the presence of marked calcification I B Reassessment after hypertension control in patients with accentuated AVS with low-flow/low gradient and preserved LVEF I B Monitoring of percutaneous implantation of aortic valve prostheses and results immediately after implantation (catheter, position, prosthesis function, regurgitation) I B Assessment of complications immediately after percutaneous implantation of the aortic prosthesis (hypotension, coronary occlusion, LV dysfunction, LVOT obstruction, marked mitral insufficiency, prosthesis displacement, tamponade, right ventricular perforation, gas embolism, aortic dissection) I B Early assessment (within 30 days) after percutaneous implantation of aortic prosthesis as to the degree of valve regurgitation (or paravalvarization) in the presence of suspected valve dysfunction I B Reassessment in less than one year of changes in hemodynamic severity and LV function in patients diagnosed with moderate AVS, before or during pregnancy, or who will be submitted to situations of increased demand (non-cardiac surgery) IIa C Good quality transthoracic 3D echocardiography for better assessment of valve morphology (especially in suspected bicuspid AV) and the degree of calcification IIb B 3D echocardiography in good-quality transthoracic image in symptomatic acute AVS with low gradient and preserved LVEF (D3), to reassess the diameter and geometry of the LVOT, to calculate the valvular area by planimetry or to calculate the valvular area by the continuity equation using the ejected volume measured directly by 3D (instead of the ejected volume derived from Doppler or two-dimensional Simpson) IIb B AVS: aortic valve stenosis; AV: aortic valve; LV: left ventricle; LVEF: left ventricle ejection fraction; LVOT: left ventricular outflow tract; 3D: three-dimensional. * Predictors of worse prognosis on resting echocardiography: marked aortic valve calcification and maximal velocity increase ≥ 0.3 m/s/year; on exercise echocardiography: increased mean pressure gradient (> 18 to 20 mmHg), absence of contractile reserve, and increased PASP (> 60 mmHg). thorough evaluation of the RV, pulmonary ring, pulmonary artery trunk and its branches. Primary PS or PR (with leaflet involvement) are more often due to congenital diseases than acquired ones. Secondary PR occurs in situations of pulmonary hypertension. There is little literature on the quantification of the severity of PR on the echocardiography, but there is a consensus that it should be done in an integrated way with pulsed, continuous and color Doppler parameters; and graded as mild, moderate, or marked. 133 PS and PR are classified, from the clinical-echocardiographic point of view, as stage C (marked asymptomatic) and D (marked symptomatic). 149 Evaluation of the pulmonary valve may be difficult for TTE. In this situation, however, the TEE does not provide additional information and is not recommended (class III). There is little data on the value of 3D echocardiography. In cases of limited transthoracic imaging or severity parameters inconclusive or discordant with clinical data, cardiac resonance is recommended as the best method. 133 3.2.7. Associated Valvar Lesions Associated valvular lesions (AVL) in our setting are frequent due to the high prevalence of rheumatic fever (RF), which reaches 70% of valvular heart disease in Brazil. 141 In the EuroHeart Survey, 51% of AVL patients had RF and 40% had degenerative valve disease. 155 Pathophysiology is complex, because it depends on the specific combination of each valve lesion, and its diagnosis is challenging because the guidelines 155