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 40 – Recommendations of the echocardiography in the evaluation of emboligenic sources and cardioembolic diseases Recommendation Class of recommendation Level of evidence Suspected cardiac embolic source, including ischemic stroke and TIA or systemic embolism I C Young patient (< 45 years) with TIA or acute ischemic stroke I C Elderly patient with evidence of non-lacunar ischemic stroke I C TIA or cryptogenic ischemic stroke I C TEE as the initial test to facilitate clinical decision-making regarding treatment (anticoagulation or cardioversion) I B Assessment of cardiac emboligenic source when non-cardiac origin has been previously identified IIb C TTE when TEE is already programmed (e.g. in the evaluation of intracardiac masses, prosthetic heart valves, thoracic aorta, or to guide percutaneous procedures) IIb C TEE when TTE findings are diagnostic of cardiac embolic sources III C TTE and/or TEE results do not guide the therapeutic decision III C TIA: transient ischemic attack; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography. 7. Atrial Fibrillation Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, whose prevalence increases with advancing age. 214,215 In the United States, it is estimated that the prevalence of atrial fibrillation will double from 5.2 million cases in 2010 to 12.1 million cases in 2030. 216 In addition to population aging, the increased prevalence of AF can be explained by the comorbidities and associated cardiovascular risks such as hypertension, heart failure, coronary artery disease, valve diseases, obesity and diabetes mellitus. 217 The risk of developing AF is 1 in 4 individuals from 40 years of age on. 218 Recent national and international guidelines have reported the classification of AF based on its presentation, duration and spontaneous termination of AF episodes. 214,219,220 Paroxysmal AF is defined as that which is reversed spontaneously or with medical intervention until seven days after its initiation. Episodes lasting longer than seven days are referred to as persistent AF. Persistent long-term AF represents cases lasting more than one year. Permanent AF corresponds to the cases in which attempts to revert to sinus rhythm will no longer be instituted. Finally, non- valvular AF is defined as AF in the absence of rheumatic MS, mechanical or biological valve or previous mitral valve repair. As part of the initial evaluation, all AF patients should have a TTE to identify structural heart diseases, including valvular heart disease, assess RA and LA size, LV and RV size and function. 184 TEE is the most sensitive and specific technique for detecting intracavitary thrombi, especially in the left atrial appendage, as a potential source of systemic embolism in AF, and can be used to guide early cardioversion or catheter ablation procedures. 214,220,221 TEE can also identify features associated with an increased risk of thrombus formation in LA, including reduced flow velocity in the left atrial appendage, spontaneous contrast in LA, and aortic atheroma. 214 Table 41 lists the main recommendations of TTE and/or TEE in patients with AF. Although the echocardiography provides important information for assessing the likelihood of achieving successful rhythm control after cardioversion, including atrial size, left ventricular systolic function, and severity of valve disease, randomized trials with a larger sample size are still lacking to understand the real prognostic value of imaging techniques in patients with AF. 222 New echocardiographic techniques such as LA evaluation by strain and 3D echocardiography are promising tools for future clinical practice. 222 8. Heart Tumors and Masses The cardiac masses comprise a broad set of lesions which may be neoplastic and non-neoplastic in nature. As regards incidence, the most frequent causes of cardiac masses are thrombi and vegetation, and rarely are tumors and pseudotumors (intrinsic and extrinsic structures that mimic a cardiac tumor). 223 Cardiac tumors are extremely rare, with secondary tumors (metastatic neoplasms) being 20 times more frequent than primary tumors. 224,225 Although the classification of these lesions for benignity or malignancy is an important predictor of prognosis, any cardiac tumor may have substantial hemodynamic or electrical consequences depending on size and location. 226 Most are detected incidentally during cardiac imaging tests or after complementary evaluation of specific clinical situations, such as after embolic event, suspected endocarditis and the possibility of malignancy involving the heart. Myxomas are the most frequent benign primary tumors in adults, followed by fibroelastomas and, finally, fibromas (much more common in the pediatric population). Primary malignant tumors, however, represent a much smaller portion of primary cardiac neoplasms, with sarcomas and lymphomas being more common. Much more frequent, as mentioned above, are secondary tumors, represented by metastases, which can occur by various forms of dissemination (hematogenous, contiguous, venous and lymphatic), associated mainly to tumors of the breast, lung, esophagus, mediastinum and melanoma. In these cases, the involvement of the pericardium occurs most of the time. 227 Echocardiography, because of its availability and applicability, is the imaging technique commonly chosen for diagnosis (Table 42). The examination may delineate the multiple cardiac structures and characteristics of a mass, 166