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 30 – Recommendations of echocardiography in patients with clinical suspicion of valvular prosthesis thrombosis Recommendation Class of recommendation Level of evidence Carrier of mechanical prosthesis with embolic phenomenon and/or acute heart failure I B Assessment to determine the hemodynamic changes caused by thrombosis IIb B TEE to complement the TTE, to evaluate the mobility and emboligenic potential of the thrombi and functional study of the prosthesis IIb B TEE: transesophageal echocardiography; TTE: transthoracic echocardiography. Table 31 – Recommendations of transthoracic echocardiography and transesophageal echocardiography in infectious endocarditis Recommendation Class of recommendation Level of evidence TTE is indicated as the first examination in the clinical suspicion of IE I B TEE is indicated on clinical suspicion of IE and negative or non-diagnostic TTE I B TEE indicated in the diagnostic suspicion of IE in patients with valvular prostheses and intracardiac devices I B Indicated to repeat TTE or TEE within five to seven days in the face of high clinical suspicion and initial negative TEE I C Echocardiography indicated for the assessment of staphylococcal bacteremia of unknown source IIa B TEE may be indicated for suspected IE, even in cases with positive TTE with good quality and reliable findings (except isolated IE) IIa C New TTE or TEE indicated for suspected new complications (abscesses, perforations, embolisms, persistence of fever, heart failure) I B New TTE or TEE indicated for the follow-up of uncomplicated IE, for vegetation size monitoring or detection of silent complications. The type (TEE or TTE) and the date of the new examination will depend on the initial findings, type of microorganism and response to therapy IIa B Intraoperative TEE in all cases of valve surgery by IE I B At the end of the treatment to establish new parameters of cardiac and valvular morphology and function I C TTE: transthoracic echocardiography; IE: infective endocarditis; TEE: transesophageal echocardiography. 3.4. Infective Endocarditis Infective endocarditis (IE) is vascular or cardiac endocardial infection resulting from invasion of microorganisms. Despite the advances in diagnostic techniques and treatment, mortality by IE remains high. 164 The profile of the disease presentation changed, with the emergence of new risk groups and more virulent microorganisms, with staphylococci emerging as the main etiological agents. Echocardiography is fundamental in the IE approach (Table 31). 165-168 The best resolution of the devices and, especially, the use of TEE are responsible for the high accuracy of the method in the diagnosis and evaluation of complications. The additional value of TEE when TTE is not diagnostic is well defined in the strong clinical suspicion of IE and/or the presence of valvular prostheses. However, the indication of TEE as an initial examination needs to be validated by new studies. 168 The definitive diagnosis of IE is based on positive blood cultures and/or characteristic echocardiographic findings. The findings following the echocardiography are major diagnosis criteria: vegetation defined by a mobile condensed mass, adhered to the valvar endocardium, mural or implanted prosthetic material; abscesses or fistulas; new prosthesis dehiscence (especially when it occurs late after its implantation) and new valve regurgitation. 169 4. Hypertension and Pulmonary Thromboembolism Pulmonary hypertension (PH) is a clinical condition associated with high morbidity and mortality, the prevalence of which is unknown due to different presentation groups. From the knowledge of the various pathophysiological mechanisms, the current classification divides PH into five groups. 170 Regardless of the mechanism, it is defined as mean pulmonary arterial pressure greater than or equal to 25 mmHg, at rest, documented by cardiac catheterization. 170 Currently, TTE is considered a method of fundamental importance in the initial evaluation of patients with clinical suspicion of PH (Table 32), since it offers information related to: diagnosis, hemodynamic status, therapeutic response and prognosis. 171 Hemodynamic data, such as pulmonary artery systolic pressure, mean arterial pressure, pulmonary artery occlusion pressure and blood volume (assessed by varying the size of the inferior vena cava), can be measured by this method. 172 The presence of RV hypertrophy, enlargement of the right cavities, anomalous movement of the septum and pericardial effusion suggest the diagnosis. The analysis of the contractile function of the RV is performed through the TAPSE, s-wave (systolic) of the tissue Doppler, RV area fractional variation and ejection fraction 160