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 26 – Recommendations of transthoracic echocardiography in associated valve lesions Recommendation Class of recommendation Level of evidence Establish diagnosis of patients with multiple murmurs I C Quantification of the severity of stenoses and associated insufficiencies I C Immediate reassessment with change of symptoms I C Annual reassessment of asymptomatic patients with AVL IIa C AVL: associated valvular lesions. Table 27 – Recommendations of transesophageal echocardiography in associated valve lesions Recommendation Class of recommendation Level of evidence Inconclusive transthoracic echocardiography I C Doubts in the quantification of valvular lesions I C Monitoring of invasive procedures for injuries that can be treated percutaneously I C provide us with specific valvular parameters alone. AVL may result from two primary valvular diseases 156 or from the combination of primary and secondary valvular disease. 157 Despite the high prevalence of AVL, there is little evidence of the best course of action to be taken in each combination. The most common combinations and their most frequent changes are reported below: 156 ● AS and MI: Increased LV pressure caused by aortic stenosis may increase the regurgitant orifice and decrease aortic transvalvular gradients, mimicking a low-flow state. 156,158 In some AS cases, there may be MR secondary to dilation and left ventricular dysfunction (tethering). Less frequent, but possible in these patients, is the presence of primary MR. ● AS and MS: are cases of difficult clinical control, in which the patient rapidly evolves to low throughput states. The gradients of both valves may be underestimated, and if the patient is inadvertently submitted to balloon catheter valvotomy of the mitral valve, acute pulmonary edema may occur due to the lack of LV compliance as a consequence of AS. 141,156 ● AR and MS: the presence of MS limits the increase in ventricular volumes frequently observed in AR; which may underestimate the severity of AR. 141,156 ● MR and AR: as a consequence of the volume overload imposed by both valvopathies, these patients usually have earlier contractile deficit than with each isolated valvopathy and progress more rapidly to the symptomatic phase of the disease. 141,156,158 Recommendations for TTE and TEE in AVL are listed in tables 26 and 27, respectively. The frequency at which TTE should be performed is debatable and depends on the type of AVL and symptomatology; in general, the examination should be repeated according to the predominant valve lesion guideline. 156 In the case of balanced lesions, TTE should be repeated with a shorter interval than the one suggested for a single valve lesion. 156 3.3. Valvular Prostheses TTE is recommended as a first line examination for the analysis of valvular prostheses. TEE may be necessary when it is necessary to better evaluate the structure and complications of valvular prostheses, recommended in cases of dysfunction (Table 28). When performing the echocardiographic examination of valvular prostheses, it is necessary to know and document the reason for the investigation, the patient’s symptomatology, the type and size of the prosthesis, the date of surgery, blood pressure, heart rate, height, weight and the patient’s body surface area.24 A detailed postoperative TTE is recommended four to six weeks after surgery, when the thoracic surgical incision is healed, thoracic wall edema resolved, and left ventricular function recovered. In this examination, it is important to record: cavitary dimensions, ventricular function, prosthetic gradients, valvular areas, presence of functional or pathological refluxes, pulmonary pressure and alterations of other valves; defining the basal conditions of valve prostheses, since the examination will be taken as reference for serial assessments. Regarding the periodicity of TTE in patients with prosthesis, a frequent assessment in asymptomatic patients with supposedly normal mechanical prosthesis is not recommended. For biologic prostheses considered to be normal, exams after five (ESC) 159 or ten years (ACC/AHA) are recommended). 127 However, annual examinations are recommended in patients with new design prostheses that have not had their proven durability in patients with aortic dilatation at the time of surgery and in patients with mitral prostheses to evaluate the evolution of tricuspid regurgitation and RV function. Echocardiographic investigation (TTE and TEE) is recommended when changes in cardiac auscultation, onset of symptoms or suspicion of prosthesis dysfunction occur. In cases where there is clinical suspicion of infective endocarditis or thrombosis, the analysis should be more thorough. 123 In cases of significant reflux of prostheses, it is recommended to perform evolutionary TTEs every three to six months. 128 TEE, due to its proximity and 158