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 41 – Recommendations of echocardiography in patients with atrial fibrillation Recommendation Class of recommendation Level of evidence TTE in the initial assessment of all patients with AF to identify structural heart disease and guide treatment I C TTE in patients with AF lasting ≥ 48 hours to decide early cardioversion with brief heparinization, without previous oral anticoagulation I B TEE in the assessment of patients before ablation or percutaneous occlusion of the left atrial appendage I B Patient with AF requiring emergency cardioversion due to hemodynamic instability III C TTE: transthoracic echocardiography; AF: atrial fibrillation; TEE: transesophageal echocardiography. such as location, mobility, morphology, size, insertion site, and potential hemodynamic consequences. It also allows for serial images over time without the need for contrast agents (iodine or gadolinium) or radiation. New techniques, such as the 3D modality, by providing additional anatomical data are capable of increasing the diagnostic accuracy of the method, assisting in the surgical strategy, as well as monitoring immediate and late results of the procedure. 228,229 The contrasted echocardiographic study represents a very useful tool, offering greater anatomical detail and assisting in the differentiation of the masses through the analysis of its vascularization (hypervascularization is frequently associated with the presence of malignancy). 230 9. Pericardial Diseases Echocardiography should be indicated in the suspicion of pericardial affections, including (but not only) pericardial effusion, pericardial mass, constrictive pericarditis, effusive- constrictive pericarditis, patients after cardiac surgery and suspicion of cardiac tamponade (Table 43). 231,232 It contributes decisively to the semiquantitative evaluation of the pericardial effusion and its hemodynamic repercussion (depending on the volume and the velocity of the collected fluid), as well as exploring the underlying etiology, whether primary (e.g. pericarditis, chylothorax) or secondary (e.g. bleeding, metastasis, myxedema, hydropericardium). The method provides information about the nature of the fluid, suggesting the presence of fibrin, clot, tumor, air, and calcium. The size of the effusion may be classified by the diastolic measurement of the echo-free pericardial space , as of small (< 10 mm), moderate (10 to 20 mm) and large (> 20 mm). 233 Findings indicative of cardiac compression may precede the clinical manifestations of the tamponade and configure an emergency situation. In this context, pericardial puncture guided by echocardiography may alleviate hemodynamic impairment and save lives. 233 Such procedure can be performed safely in centers with experience, avoiding radiation associated with fluoroscopy and/or cost of surgery, which makes pericardiocentesis guided by echocardiography the procedure of choice. 234 Individuals with chronic or recurrent pericardial effusion, not responsive to the proposed clinical treatment, may be referred for elective pericardial drainage after serial evaluation. The spectrum of echocardiography utilization in pericardial disease also includes congenital defects, trauma, neoplasia, cysts, CT after radiotherapy and the differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy. In this differentiation, findings compatible with constriction are: exacerbated decrease (> 25%) in the E-wave velocity of the mitral flow in the first beat after inspiration, normal tissue Doppler mitral annular velocity (e’ > 7 cm/s) and annulus paradoxus (e’ septal > e’ lateral). 233 Table 42 – Recommendations of the echocardiography in patients with intracardiac masses and tumors Recommendation Class of recommendation Level of evidence Assessment of individuals with clinical suspicion (signs and symptoms) or patients with conditions predisposing to cardiac tumors I C Carriers of malignant neoplasia with high risk of cardiac involvement I C Evolutionary follow-up after surgical removal of cardiac tumors with high potential for recurrence (such as myxomas) I C TTE for complementary anatomical and functional assessment in cases in which TTE was not definitive I C TEE for complementary intraoperative assessment I C 3D echocardiography to search for additional anatomical information not seen in 2D TTE I C Use of echocardiographic contrast for differential diagnosis and vascularization analysis IIa B Patients with direct relatives with family history of myxoma IIa B Patients whose results of the examination findings will not imply in therapeutic decision III C TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; 3D: three dimensional; 2D: two dimensional. 167