ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 due to the lack of adequate probes. In this case, even the XR scoping can be discarded. B) Procedures for occlusion of atrial septal defects: there are devices for occlusion of defects of the atrial septal defect, ostium secundum, as well as patent foramen ovale. The examination can be performed in both, mainly TEE or intracardiac echocardiography, where it is possible to assist in the choice of the device, its positioning, immediate result and rapid identification of complications. TTE may be preferable to TEE in selected patients. 251 C) Procedures for occlusion of ventricular septal defects: TEE should be performed to better understand the anatomical aspects, the procedure itself and possible complications. Acquired ventricular septum defects, such as those after trauma or after acute infarction, may also be treated with the aid of echocardiography, presenting the same value in the procedure. D) Procedures for occlusion of ductus arteriosus persistence: in this situation, echocardiography is disregarded, since catheterization during the procedure is usually sufficient for success. 13.3. Electrophysiology Procedures The echocardiography mainly supports the procedure of puncture of the atrial septum, usually through TEE, or alternatively by intracardiac echocardiography. In the procedure of ablation or implantation of pacemaker the echocardiography is dispensable, since the electrical mapping provides the necessary information. In the presence of complications, such as perforation of a chamber with pericardial effusion and tamponade, the echocardiography is normally requested. 13.4. Alcoholic Ablation in Hypertrophic Cardiomyopathy One of the treatments for symptomatic patients consists of alcohol ablation of the segment where there is a greater degree of hypertrophy and related to intraventricular obstruction in its exit pathway. TTE is more used, and there is no restriction on the use of TEE. Prior to alcohol infusion, the septal artery is catheterized and a solution is infused. At this time, the echocardiography should assess whether the contrast-enhanced myocardial segment corresponds to the portion of the myocardium associated with the obstruction and if it does not occur in all transmurality of the segment, which is undesirable. The Doppler study estimates the gradient of obstruction and also the degree of mitral regurgitation. After alcoholic ablation, we repeat the measurement of gradients and mitral regurgitation, whose falls indicate successful treatment, and possible complications are investigated. 13.5. Left Atrial Appendage Occlusion An alternative, when it is impossible to carry out adequate anticoagulation in patients at high risk for atrial arrhythmia embolism, is occlusion of the left atrial appendage. TEE is mandatory in this treatment the, as it not only helps the transseptal puncture, but also allows adequate appenddage measurements, which select the dimensions of the occluder device. Still in the room, the TEE guides the procedure, confers its result and makes it possible to diagnose complications. 13.6. Treatment of Heart Valves A) Percutaneous treatment of mitral regurgitation: among the several treatments proposed, the only one that is commercially available is Mitraclip®. In this treatment there is a mimicry of the Alfieri surgery, where there is the formation of a double mitral orifice. To do so, a metallic clip is inserted through the vein, which advances to the LA after puncture of the atrial septum and is positioned so as to reduce severe mitral regurgitation. In this case, no step is performed without the TEE, considering that the 3D image provides better understanding of the procedure. B) Balloon catheter mitral valvotomy: the use of balloons for the treatment of severe rheumatic mitral stenosis is a safe and efficient alternative. The echocardiography prior to the procedure provides information that can predict the chance of success. 252,253 In the intervention, the TEE is preferable, and the morphological aspects of the mitral valve should be reviewed. During the inflation of the balloon (or balloons), the echocardiography allows to detect proper positioning. Immediately after the procedure, measures are performed with the objective of evaluating the success of the procedure and the complications that may have occurred. C) Balloon catheter aortic valvotomy: the use of this therapy is currently safeguarded as the last alternative for the treatment of aortic stenosis or as a bridge to compensate for the clinical condition and subsequent implantation of a prosthesis via cardiac catheterization or surgery. The echocardiography can be used to evaluate immediate results and complications. D) Transcatheter implant of aortic valve prosthesis: the indication of the percutaneous implantation of aortic valve prosthesis is conditioned to clinical and morphological aspects of the aortic valve. It is necessary to diagnose severe aortic stenosis prior to the procedure, as well as the analysis of the aortic complex, which selects the size of the most appropriate device for the procedure, directly related to its success. The preference is for the use of TEE, especially with 3D image. During the procedure, it is necessary to review the severity of valve stenosis by measuring the gradients and estimating the effective flow orifice. Still, measurement of the aortic complex and especially of the area/perimeter of the aortic ring, performed only through the 3D echocardiography is necessary. The value obtained is optimally related to tomography measurements that are usually used to select the device. 254 Whether femoral or transapical, monitoring of the arrival of the prosthesis to the aortic valve is performed, as well as the aid of the ideal positioning, prior to its opening. After implantation, the TEE should provide data on adequate prosthesis expansion, presence and degree of prosthetic and/or paraprosthetic regurgitation. Complications of the procedure are part of the echocardiography investigation. 13.7. Treatment of Prosthetic Dysfunction A) Valve in valve: The term “valve in valve” means the implant of a prosthesis via a catheter over a dysfunctioning bioprosthesis. It can be made in prostheses in aortic and mitral 171