ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 not allow the analysis of all segments of the aorta, such as the aortic arch and the distal descending. In this case, it is necessary to use other imaging methods such as TEE, computed tomography or magnetic resonance imaging. 154,243 The TEE allows the realization of excellent resolution images due to the proximity of the esophagus to the thoracic aorta. Despite the multiplanar sections offered, a small segment of the ascending aortic junction with the aortic arch is not visualized due to the interposition of the trachea. 154 The precise diagnosis of acute aortic syndromes, such as aortic dissection, intramural hematoma, penetrating ulcer and rupture of aortic aneurysms, is fundamental in the therapeutic strategy to be adopted. In unstable patients with suspected acute aortic syndrome, the imaging modality chosen will depend on local availability and expertise. In general, TTE is performed as an initial investigation (class I), complemented with TEE and/or tomography (both class I). The TEE shows good accuracy, mainly in the exclusion of artifacts caused by reverberations of the anterior wall of the LA and the pulmonary artery. 244 Depending on the clinical suspicion, the diagnostic investigation should proceed with two or more imaging examinations due to the possibility of false negatives. 245 11.2. Pulmonary Artery The trunk of the pulmonary artery and the initial portion of the pulmonary branches can be assessed to TTE. TEE is more accurate, allowing a greater examination of the pulmonary artery and its branches, which allows a better appreciation of thrombi in the proximal territory of the pulmonary artery. Dilations of these vessels can also be diagnosed. Pulmonary artery dilatations are uncommon lesions and may be associated with different etiologies, such as congenital heart diseases, systemic vasculitis, collagenosis, infections and traumas. 11.3. Veins Anomalies of the superior and inferior vena cava can be diagnosed by TTE and/or TEE. The presence of thrombi in these pathways and the extension of tumors into the right cavities can be evaluated. TEE is particularly useful for the identification of thrombus or vegetation in the superior vena cava in patients with long-stay catheters and in cases of pulmonary vein stenosis after AF or atrial flutter ablation procedures. The persistence of the left superior vena cava should be suspected in the presence of dilated coronary sinus and the diagnosis can be made using intravenous injection of agitated saline solution, which will first contrast the coronary sinus and then the right cavities. In this case, it is important to emphasize the need to exclude anomalous drainage of the left pulmonary vein via the vertical vein. 246 12. Intraoperative Echocardiography in Cardiac and Non-Cardiac Surgeries 12.1. Introduction Intraoperative echocardiography is a technique for monitoring cardiac and non-cardiac surgeries that allows a rapid and real-time assessment of anatomic and functional cardiac features (global and segmental function, valvular function, volume and vascular resistance), aortic and phenomena with embolic potential. 247,248 In non-cardiac surgeries, clinical information obtained by intraoperative echocardiography is often complementary to data provided by other hemodynamic monitoring devices (e.g., central venous catheter, pulmonary artery catheter, or arterial line). 247,249 In the case of cardiovascular surgeries, the intraoperative echocardiography can also contribute with real-time dynamic information and images of the cardiac structures to plan, guide and evaluate the immediate result of the surgical intervention. 250 12.2. Modalities of Intraoperative Echocardiography A) Transesophageal: most widely used in open, minimally invasive or percutaneous cardiac surgeries, as well as in non-cardiac surgeries. It has the advantage of not entering the sterile field and of not disturbing the surgical procedure, allowing continuous monitoring. It is a relatively safe modality when performed by properly trained professionals. The contraindications are the same as for the conventional TEE. In young children, the use of intraoperative TEE should be considered on a case-by-case basis, based on the unique risks of these patients (e.g., bronchial obstruction). 248 B) Epicardial or epiaortic: are an alternative for monitoring open heart surgeries in which there is absolute or relative contraindication of manipulation of the esophagus, or blood dyscrasia. In these embodiments, the linear or sectoral transducer is wrapped in a sterile cap and applied directly over the heart or aorta. The epiaortic technique is a very important tool in patients with advanced atheromatous disease, since it allows the choice of a suitable site for cannulation and aortic clamping. 249 C) Transthoracic: may be considered as a monitoring alternative for percutaneous or non-cardiac procedures that are performed with superficial sedation, or in cases in which the patient has absolute or relative contraindication of esophageal manipulation. In this modality, the examination can be performed serially during the procedure, or at specific times as needed (e.g., in cases of hemodynamic instability, to guide endomyocardial biopsy). D) Intracavitary: little used, more restricted to percutaneous procedures. 12.3. Recommendations in Cardiac and Thoracic Aorta Surgery The main objectives of the use of intraoperative echocardiography in cardiac and thoracic aorta surgeries are: to confirm and refine the preoperative diagnosis; to detect new or unsuspected morphophysiological alteration; adjusting the surgical or anesthetic plane according to the findings; to guide the positioning of cannulae or devices; to evaluate the presence of air, masses and thrombi in cardiac cavities and their embolic potential; to evaluate segmental and global left ventricular function and cavitary pressures; and to evaluate the immediate outcome of the intervention. 244,245,249 The main recommendations in this scenario are in the Table 44. 169