In accordance with the “Standards for the Elaboration of Guidelines, Positions andNormations” sanctioned by the Brazilian Society of Cardiology, this document waswritten to update the “Echocardiography Indication Guidelines” of 2009. The newdocument is not intended to be a comprehensive review of echocardiography, butrather an indispensable basic guide to support the rational clinical decision-makingof the physician requesting the exam for adult patients. Although it considers therecent technological advances of echocardiography, its purpose is not to describe indetail echocardiography methods, but to summarize in a clear and concise way themain situations in which echocardiography brings benefit to the diagnosis and/ortherapeutic orientation of the individual. This manuscript chose to highlight theclass of recommendation, as described below:Class I: conditions for which there is conclusive evidence or, in theabsence thereof, general agreement that the examination procedure isuseful and safe.Class II: conditions for which there is conflicting evidence and/ordivergence of opinion on the utility and/or safety of theexamination.Class IIa: evidence or opinions favorable to the examination. Mostexperts approve.Class IIb: utility and/or safety less well established, with divergentopinions.Class III: conditions for which there is evidence or consensus that theexamination is not useful and, in some cases, may even be harmful.In addition, the level of evidence was also described, as follows:A: several concordant randomized clinical trials or robustmeta-analyses;B: less robust meta-analysis data or single randomized clinical study orobservational studies;C: expert opinion.Thus, it was agreed that all the tables with recommendations for the use ofechocardiography in the different clinical scenarios include columns with class ofrecommendation and level of evidence.2 of thedimensions of the cavity and the thickness of the LV. Thus, parameters ofventricular systole analysis are derived as: (1) percentage of systolicshortening of the left ventricular dimension, represented by the differencebetween the final diastolic and the final systolic dimensions, divided by thefinal diastolic one; (2) mean corrected circumferential shortening velocity,corresponding to the ratio between the percentage of systolic shortening of theleft ventricular dimension divided by the ejection time corrected by thepreceding R-R interval ; (3) ventricular volumes at the end of systole and diastole,calculated from the method by Teichholz et al.;3 and (4) LV ejection fraction (LVEF), obtainedfrom the difference between the diastolic and systolic ventricular volumes(volume ejected by systole), divided by the diastolic volume. The M-modeanalysis is highly reproducible and presents high temporal resolution for theanalysis of ventricles without spatial deformation.4 However, M-mode measurements, in general,adequately determine global systolic function only when there are no segmentalchanges, remodeling and/or geometric alterations of the LV.4 With the advent of 2Dechocardiography, a greater amplitude of the LV spatial observation wasacquired, allowing better analysis of the left ventricular systolic function,when compared to the one-dimensional analysis. This occurs in situations wherethere are changes in left ventricular geometry, such as apical aneurysm andother segmental changes resulting from coronary artery disease. The analysis of2D left ventricular systolic function can be performed qualitatively  or quantitatively of LVEF. Visual estimation is highly dependent onthe training of the operator, which can result in inaccuracy of reproduction ofresults. The quantitative method for volume and systolic function analysis ofthe most widespread and widely valid 2D-LV is the biplanar disc technique(modified Simpson’s rule), in which the total volume is calculated based on thesum of the volumes of small cylindrical discs in apical cuts 4 and 2 LVchambers, with the intention of minimizing the effects of modifying theventricular geometry in LVEF calculation.4 Normal volume and LVEF values, calculated using 2Dechocardiography, show different values depending on gender. Thus, for men, thefinal LV diastolic volume is between 34 and 74 mL/m2, the final LVsystolic volume is between 11 and 31 mL/m2 and LVEF is between 52 and72%; LV final diastolic volume is between 29 and 61 mL/m2, LV finalsystolic volume is between 8 and 24 mL/m2 and LVEF is between 54 and74%.4 The 2D LVEFanalysis may present inaccuracies during the shortening of LV (foreshortening)or inadequate acoustic window, and when there are coexistent geometric changesin the apical 4 and 2 LV chambers.4 The analysis of LV segmental contractility by 2Dechocardiography represents a semiquantitative technique to assess regionalsystolic function, which has shown good application in clinical practice,especially for stress echocardiography . Tissue Doppler, a technique used in the analysis of diastolicfunction, can also be used to assess global and segmental LV systolic function.The systolic velocity of the ventricular myocardium (s-wave), when measured inthe region of the mitral annulus, reflects the longitudinal myocardial systolicshortening and may be reduced early in patients with diastolic dysfunction andnormal ejection fraction.5 Thismethod may also be useful for ventricular synchrony analysis and as a complementin stress echocardiography, although it does not allow adequate evaluation ofsystolic function in the apical LV segments and depends on the angle ofincidence of the ultrasound beam.The analysis of left ventricular (LV) systolic function is a primary indicationof the use of echocardiography. Echocardiographic analysis of LV systolicfunction can be performed using older techniques such as M-mode, 2Dechocardiography, and even more modern techniques, such as three-dimensional(3D) echocardiography or research of myocardial deformation (strain). The M-modehas been used since the 1950s for cardiac structural analysis and provideswidely standardized measurements11 Most recent algorithms allow the calculation of LVEFand LV volumes in a semi-automatic way, with great correspondence with theanalysis performed by nuclear magnetic resonance.12 However, 3D echocardiography presentsdifficulties in relation to low temporal resolution and to the dependence ontransthoracic echocardiographic image quality.43D echocardiography represented an improvement over 2D echocardiographicobservation of LV function, once it does not present the limitations of the 2Danalysis in ventricles with altered geometry, in addition to being morereproducible and better correlated with the gold standard provided by nuclearmagnetic resonance.14 The analysis of the cardiac mechanics can beperformed from parameters derived from myocardial deformation, such as twist,torsion and LV rotation. In order to obtain ventricular strain, the mostcommonly used technique takes into account the movement of gray points in themyocardium during the cardiac cycle (speckle tracking technique).14 Global 2D strain has the advantages of not depending onthe angle of the ultrasound beam (as in tissue Doppler) and of presenting anindependent prognostic LVEF value.4 However, it does not yet present a standardized value ofnormality among the different manufacturers of echocardiographyequipment.4 The LVglobal longitudinal strain (GLS) has been the one most commonly used inpractice, which is useful for the detection of subclinical myocardialdysfunction, even when LVEF is preserved; for example: evaluation ofcardiotoxicity after the use of chemotherapy for antineoplastic treatment,rejection after heart transplantation, severe aortic stenosis, hypertrophiccardiomyopathy and myocardium infiltrative diseases.19The understanding and analysis of LV mechanics and systolic function can also bedetermined by the measurement of ventricular strain. Strain is defined as themodification of length of the myocardial segment (in %), considering thedifferent spatial arrangements of the myocardial fibers. In this way, thelongitudinal, circumferential and radial strain  is calculated. Thestrain can be calculated for each of the LV segments or for all segments .21 Furthermore, in severalcardiopathies, the diastolic dysfunction precedes the systolic one. Diastolicdysfunction is usually the result of altered relaxation, with or withoutreduction of restorative forces (early diastolic suction), and increased LVstiffness, leading to elevated LV filling pressures.20 When pulmonary capillary pressure exceeds 12mmHg, or final diastolic LV pressure exceeds 16 mmHg, filling pressures areconsidered high.21 Elevationof filling pressures occurs as a compensatory response to maintain adequatecardiac output, and its estimation is important not only for the diagnosis ofcardiac insufficiency but also for the definition of its severity and responseto treatment.21 It isrecommended that the non-invasive analysis of diastolic function be performed bythe integrated approach of several techniques, the most important ones being:Pulsatile Doppler of the mitral flow, tissue Doppler of the mitral valveannulus, left atrial volume (LA) indexed by body surface and tricuspidregurgitation velocity.20Pulmonary venous flow and Valsalva maneuver can be used as additional parametersin specific cases, which are useful in differentiating the degrees of diastolicdysfunction.20 Whilepulsatile and tissue Doppler velocities reflect the instantaneous fillingpressures of the LV, the measurement of the LA volume reflects the cumulativeeffect of filling pressures over time and, therefore, this index is the chronicexpression of diastolic dysfunction.22 However, it is important that other causes of LAenlargement are discarded and that this data is taken into consideration alongwith the patient’s clinical condition, chamber size and Doppler indices for theevaluation of diastolic function.The evaluation of LV diastolic function is an integral part of routineechocardiography analysis, especially in patients with dyspnea or suspectedheart insufficiency.21 For the group of patients withsystolic dysfunction and those with preserved systolic function concomitant withthe presence of cardiac disease ,the integrated use of the information allows us, in most cases, to estimate theventricular filling pressures and the graduation of diastolicdysfunction.20 Threepatterns of diastolic dysfunction are defined, in ascending order of severity:grade I ;grade II ; and grade III. To define the presence of increased filling pressures in this group withheart disease, we must first analyze the mitral flow, before other parameters.The relationship between E and the atrial diastolic velocity of the mitralinflow (A) E/A ≤ 0.8 (with E-wave ≤ 50 cm/s) is compatible withnormal filling pressures and isolated abnormal relaxation, while the relationE/A ≥ 2 is consistent with elevated filling pressures. However, for caseswith an E/A > 0.8 and < 2, an abnormalityof at least 2 of the following 3parameters is required: E/e’; tricuspid refurgitation velocity; and LA indexedvolume. In some cases, the definition criteria for diastolic dysfunction are notcompletely fulfilled, and thus the degree of diastolic dysfunction can bereported as indeterminate.20This algorithm for the evaluation of diastolic dysfunction from theechocardiography has recently been validated in a multicenter study whichassessed patients with and without left ventricular systolicdysfunction.23Non-invasive evaluation of filling pressures by echocardiography correlated withthe diastolic pressures measured by catheterization, showing greater accuracythan isolated clinical parameters.23In individuals with preserved systolic function and without structural heartdisease, diastolic dysfunction is considered if there is a change of more than50% of the following 4 parameters: relationship between the early diastolicvelocity of mitral inflow (E) and the early diastolic velocity of the mitralannulus (e’) E/e’ mean > 14; septal e´ velocity’ < 7 cm/s or lateral <10 cm/s; tricuspid regurgitation velocity > 2.8 cm/s and LA indexed volume> 34 mL/m.20 Some patients, even with grade I diastolicdysfunction defined at rest, become symptomatic only during exercise andtherefore it may be useful to analyze filling pressures during physical stress(diastolic stress echocardiography).24 Patients withdiastolic dysfunction are unable to increase ventricular relaxation withexercise, when compared to normal subjects, with increased filling pressures,which can be identified by increased E/e’ ratio and tricuspid regurgitationvelocity.24 In normalpatients, velocities of E and e’ increase proportionally and the index remainsconstant. Finally, the evaluation of diastolic function using techniques derivedfrom strain and strain rate is promising, but requires further studies toestablish its additional clinical value.20It should be noted that the parameters for evaluation of diastolic function maypresent important limitations in specific situations, such as hypertrophiccardiomyopathy, mitral annular calcification, severe mitral regurgitation,cardiac transplantation and cardiac arrhythmias.25Cardiomyopathies are confined to the heart or are part of generalized systemicdisorders. The classification is based on functional or structural changes inthe following subtypes: dilated, hypertrophic, restrictive, and arrhythmogeniccardiomyopathy (or dysplasia) of the right ventricle (RV), more recentlyreferred to as arrhythmogenic cardiomyopathy.26 Subsequently, as the knowledge on the geneticsfoundations of cardiomyopathies developed, other classifications have beenproposed, subdivided into genetic, acquired and mixed.26 More recently, channelopathies and relateddisorders, such as long and short QT syndrome, Brugada syndrome andcatecholaminergic polymorphic ventricular tachycardia, have been included in thegroup of cardiomyopathies, since they are cardiomyocyte diseases characterizedby arrhythmogenic electrophysiological dysfunction.26Cardiomyopathies are a heterogeneous group of myocardial diseases associated withmechanical and/or electrical dysfunction, which usually exhibit inappropriateventricular hypertrophy or dilatation, due to a variety of causes, oftengenetic.27The criterion to define LV dilation is the final diastolic diameter > 2.7cm/m2. With increased gradual dilatation on the short axis,the LV cavity becomes spherical, with sphericity index (long/short axisdimension) close to 1 .28 Wall thickness is usually normal, but themyocardial mass is increased. The degree of impairment of systolic functionis variable, and systolic dysfunction is often progressive. LV volumes arecalculated in a more reproducible and accurate way by using the 3Dechocardiography. Abnormalities associated with diastolic function may bepresent, contributing to the variation in the clinical and hemodynamicpresentation of DCM. The involvement of the RV can be evidenced, but it isnot a criterion for the diagnosis of DCM.29 Notably, DCM is associated with anincreased risk of severe arrhythmia, indicating the pathological involvementof the cardiac conduction system. Complex remodeling of one or bothventricles contributes to the secondary features of DCM, which includefunctional mitral and tricuspid regurgitation, enlarged atria, intracavitarythrombi, and evidence of low cardiac output.28 In the context of DCM, the analysis ofdiastolic function aims to estimate the filling pressures; and the mitralflow pattern is usually enough to identify patients with increased LApressure. E-wave deceleration time is an important predictor of outcomes inthese patients.30 Otherdiastolic dysfunction parameters, including the E/e’ ratio, have goodcorrelation with pulmonary capillary pressure and have an additionalprognostic value for LVEF.30It is characterized by LV dilation associated with global systolicdysfunction, in the absence of volume or pressure overload. The prevalenceof dilated cardiomyopathy (DCM) is variable, reflecting the geographical andethnic differences, as well as the methodologies used. A prevalence of 1:250is estimated, based on the frequency of the left ventricular dysfunction asan expression of DCM.28 Keyechocardiography indications in the evaluation of DCM are displayed in 28 Several echocardiographicparameters were used to assess mechanical desynchrony in patients with DCM.However, the broader role of echocardiography in the selection of patientsfor cardiac resynchronization therapy remains undefined. Currently,echocardiographies are limited to patients with borderline QRS duration (120to 149 ms), whose presence of intra- or interventricular desynchrony mayprovide additional information.28 The echocardiography guiding the placement ofelectrodes at the site of greater mechanical activation delay  showed benefit in heart failure free survival, with a morefavorable impact on ischemic heart disease compared to DCM.31Echocardiography is the imaging method of choice for the evaluation of DCMpatients, providing key data not only for diagnosis, risk stratification andtreatment definition, but also plays a key role in the evaluation of familymembers.32 Apicalaneurysm is a typical CCM finding and is useful in the differentialdiagnosis of dilated cardiomyopathies.33 The morphology of aneurysms is variable andnon-standard sections are often required for the identification of apicalcontractile changes. The presence of thrombi within the aneurysms isfrequent and associated with cerebral thromboembolic events.34 Diastolic dysfunction isuniversally present in patients with CCM and heart failure.35 The main echocardiographicparameters previously studied with a prognostic value in CCM are LVEF, rightventricular function, LA volume and E/e’ ratio.36The contractile function of the LA evaluated by the negative peak of theglobal atrial strain was an independent predictor of clinical events in theCCM.35 Theheterogeneity of systolic contraction, quantified by mechanical dispersionto speckle tracking, was associated with ventricular arrhythmias in patientswith CCM, regardless of LVEF.37 Recommendations for performing TTE in CCM are set outin 38Chagasic dilated cardiomyopathy (CCM) presents similar characteristics toidiopathic DCM, but with predominance of segmental changes in contractility,especially in the basal segments of the inferior and inferolateralwalls.28 Also in class IIa and IIbindications, it is necessary to recognize the reduction of the LVEF below35%, being contraindicated when this value is not present. Therefore, in thepossibility of indication for cardiac resynchronization therapy,transthoracic echocardiography is a class I indication, level of evidence C.In this examination, it is mandatory that LVEF be obtained by the Simpson 2Dmethod, with a description, in the report, of their volumes. It is alsopossible to use the 3D methodology, of less variability, although stillunproven in this clinical scenario. Approximately 30% of patients do notpresent clinical improvement or significant reduction in LV final systolicvolume.39 TTE canprovide information that helps identify a greater probability of successfultreatment response, such as the presence of mechanical, inter- andintraventricular desynchrony, the presence of myocardial reserve anddetermination of the last site of activation, which may be associated withhigher degree of fibrosis. To this end, the use of a variety of methods isencouraged, from the visual evaluation of 2D echocardiography,M-mode,40 tissueDoppler and, especially, the use of a technique that evaluateslongitudinal41 orradial myocardial deformation.43 In theevaluation of successful response to treatment, it is expected, in regardsto imaging, mainly negative remodeling to be observed, usually characterizedby reduction of 15% of the initial systolic volume, analyzed between 3 and 6months of the implant.44 In case the negativeremodeling and/or the clinical improvement of the patient is not met, onepossibility is to adjust the pacemaker, guided by TTE, to optimize theatrial and ventricular stimulus intervals. The main correction in this caseseems to be adjustment of the atrial and ventricular stimulus intervals,guided by the echocardiography, which allows for retrieval of theresults.46Cardiac resynchronization therapy is an established treatment option forpatients with heart failure with marked reduction of LVEF. Theechocardiography is fundamental in the indication, estimation of success andevaluation of the results of this procedure and may also contribute to therecovery of unfavorable results. This treatment is indicated as class I inpatients with heart failure (New York Heart Association (NYHA) functionalclass II, III or IV), with LVEF lower than 35%, optimized medication andleft bundle branch block with QRS duration above 150 ms.48 In the presence of early graft dysfunction, theechocardiography usually shows an overall reduction in myocardial function(LVEF < 45%), loss of the contractile reserve, increase in RV volume withsystolic dysfunction (tricuspid annular plane systolic excursion - TAPSE< 15 mm or RV ejection fraction < 45%).47 A comprehensive echocardiographicexamination  is recommended in the sixth month aftercardiac transplantation), which will serve as the baseline for assessinggraft morphology and function during sequential and regular follow-upexaminations  and 3D evaluation of the volumes and function ofcardiac chambers and tricuspid valve , for providing a more accurate andcomprehensive analysis .47The echocardiography is the main noninvasive imaging modality as well as themost versatile one in the evaluation and monitoring of patients aftercardiac transplantation, providing accurate information on morphology andgraft function. From the immediate postoperative period up to the moment ofhospital discharge, serial echocardiographic exams are recommended both toidentify and monitor surgical complications and early graft dysfunction,whether due to primary or secondary causes .47 However, anechocardiographic study with no change from the baseline study has a highnegative predictive value for acute rejection of the graft. On the otherhand, if several echocardiographic parameters are abnormal, the probabilityof acute rejection of the graft increases considerably.47 When an abnormality isdetected, a careful review of the images of the present study and thebaseline study (side-by-side) is highly recommended .47 GLS is anadequate parameter to assist in the subclinical diagnosis of graftdysfunction, regardless of etiology, in addition to an adverse eventpredictor, when comparing the variations of values occurred during serialevaluations .50 The association of GLSwith endomyocardial biopsy helps to characterize and monitor an episode ofacute rejection or global dysfunction.47 Pericardial effusion should be serially assessedfor extent, location and hemodynamic impact . In thecase of a recently detected pericardial effusion, the hypothesis of acuterejection should be considered, taking into account the patient’s global andclinical echocardiographic evaluation.51 Cardiacgraft vascular disease is the main cause of late complication; and thedobutamine stress echocardiography has proven to be a safe and accuratemethod to identify the affected patients.54 The evaluation of thecoronary reserve flow, as well as the sonographic contrast infusion tohighlight the borders and to evaluate the myocardial perfusion , whencombined with stress echocardiography, have been shown to increase theaccuracy of the diagnosis of graft vascular disease.59 Thus, dobutamine stress echocardiography alone or in association with the evaluation of the flow ofcoronary reserve and/or with the use of sonographic contrast  may be an adequate noninvasive alternative to routine coronaryangiography to assess the presence of cardiac graft vasculopathy, providedthat the medical center has good experience with methodologies.It should be noted that there is no single isolated echocardiographicparameter that can be reliably used to diagnose acute rejection.60 Furthermore, the use ofechocardiography during the procedure allows immediate recognition andmanagement of a possible complication.In addition to the role of cardiac graft monitoring, intraoperativeechocardiography can be used as an alternative to fluoroscopy to guideendomyocardial biopsies, avoiding repeated exposure to X-rays, particularlyin children and young women . Whether in transthoracic ortransesophageal mode, the echocardiography allows a simultaneousvisualization of the soft tissues and the biotope, guaranteeing greaterbiopsy safety in different regions of the RV with a reduction in thecomplication rate.61Before starting anti-neoplastic treatment, it is essential to access therisk of CT,62 taking intoconsideration: (a) the specific risk of the drug used in chemotherapy, assome of them may affect the cardiac function ,while other ones, the vascular function , or both(bevacizumab); (b) the use of radiotherapy, as it increases the risk ofheart failure when concomitant with anthracyclines, pericardial lesion(constrictive pericarditis) and coronary artery disease; (c) the presence ofprevious risk factors, such as age > 65 years, female gender,hypertension, diabetes mellitus, coronary artery disease and history ofheart failure. All patients receiving potentially cardiotoxic drugs shouldbe periodically monitored for CT signs, which can be classified according tothe injury the drug used produces.63 CT Type I, potentially irreversible,anthracycline-related dose, is dose-dependent, mainly at > 250 to 300mg/m2 . It most commonly occurs in the first yearof chemotherapy, or even two to three decades after completion of treatment,as progressive systolic dysfunction. It may rarely present as an acutesystolic dysfunction, immediately after dosing. Type II CT, which ispotentially reversible, mainly related to trastuzumab (used in the treatmentof breast cancer in patients with increased HER2 receptor expression), hasno relation to the cumulative dose.63 Such information is the basis for the algorithms ofserial left ventricular function monitoring during and after treatment ofcancer patients, published by the European Association of CardiovascularImaging (EACVI) and the American Society of Echocardiography(ASE).3 The mosthistorically used parameter is LVEF, calculated by TTE using the Simpsonbiplanar 2D method.4 LVEFvalues between 53 and 73% should be considered normal in the evaluation.The main advantages of 2D TTE in relation to other imaging modalities, suchas radioisotope ventriculography and magnetic resonance imaging (MRI), are:greater availability, lower cost, possibility of serial re-evaluations andgreater safety . 3D TTE, used in sequential and comparative MRI evaluationsfor LVEF assessment, showed reproducibility comparable to MRI and betteraccuracy than 2D TTE,64being more indicated, when available, in the serial evaluation of thesepatients.65Current cancer therapy is quite effective in some types of tumors, though itcan induce cardiovascular complications. Cardiotoxicity (CT) induced bycancer treatment is recognized as the major cause of morbidity and mortalityin cancer survivors.3 as thedecrease of LVEF > 10 percentage points to values < 53% and should beconfirmed after 2 to 3 weeks of diagnosis by new imaging. This decrease mayor may not be accompanied by symptoms of heart failure and may or may not bereversible. One of the major limitations of the use of LVEF for CT diagnosisin the follow-up of these patients is that changes in LVEF occur later. Inorder to minimize the risk of developing irreversible cardiomyopathy, it isessential to identify early signs of CT, since the administration ofcardioprotective medication in this phase may result in an improvement incardiac function.66 Thus,the search for a technique that allows subclinical and early detection of CTbefore LVEF decrease or the onset of clinical symptoms has been an area ofintense investigation. In this scenario, the use of GLS gained importance,evaluating myocardial deformation. Such technique has inter- andintraobserver reproducibilities smaller than the LVEF obtained by the 2DTTE, but is limited by the variability of normal values according to thebrand of the equipment used, age and gender of the patients.67 Systematic reviewconfirmed the prognostic value of the alterations in GLS for CT, precedingthe LVEF decrease obtained by 2D or 3D TTE.15 The consensus recommends serial GLSevaluation in patients at risk of CT, with subclinical left ventriculardysfunction suggestive of a fall of > 15% of the baseline value, evenwithout LVEF change.63 Therelative decrease between 8 and 15% suggests a more rigorous follow-up. GLSVariation of < 8% is consistent with absence of subclinicaldysfunction.63Although some studies have drawn attention to changes in diastolic functionfollowing chemotherapy,68 there is no current evidence to support suchparameters as indicative of CT.63 A use of biomarkers in the assessment integratedwith imaging methods in chemotherapy patients evidenced the importance oftroponin I (TnI) with a high negative predictive value in the detection ofCT.69 It isprobable that patients who do not evolve with TnI elevation have lowerprobability of events and perhaps less need for imaging tests in subsequentevaluations.70 There is still no robustscientific evidence based on randomized clinical trials to support thealgorithms proposed by the European Society of Oncology71 and the consensus of EACVIand ASE,63 in thefollow-up of these patients; however, these documents represent currentknowledge in the area. The orientation of the EACVI - ASEconsensus63 to thepresent moment is:The definition of CT due to chemotherapy was defined by the consensus ofthese two societiesInitial evaluation of left ventricular function before the startof chemotherapy in patients who will use potentially cardiotoxicchemotherapeutics. If it is not possible in all patients, it isrecommended in those at high risk for the development of CT: age> 65 years, previous left ventricular dysfunction, predicteduse of high doses of anthracyclines (type I) or combination oftype I and II drugs. To perform the LVEF assessment by the 3DTTE if available or, alternatively, by the 2D TTE (Simpsonmethod). It is desirable that the evaluation by GLS and TnI iscarried out. If not possible to perform GLS, report the S-waveof the medial and lateral tissue Doppler of the mitral annulus.Further monitoring of left ventricular function is recommendedafter this initial evaluation, depending on the chemotherapy tobe initiated.2. For doses > 240mg/m2, evaluate left ventricular function beforeeach additional 50 mg/m2 cycle at the end ofchemotherapy and after 6 months.Type I drugs (anthracyclines): evaluate left ventricular function(2D/3D LVEF and GLS) at the end of chemotherapy and after 6months at dose < 240 mg/mType II drugs (trastuzumab): evaluate left ventricular functionevery three months during chemotherapy.Patients receiving trastuzumab following anthracycline treatment:assess left ventricular function every three months duringchemotherapy and six months after its completion.72 Minorhypertrophy degrees (13 to 14 mm) may also diagnose HCM, particularly amongrelatives of these patients. TTE is considered the initial imaging fordiagnosis, stratification of the risk of cardiac events and management ofpatients with HCM. Among the parameters to be evaluated in HCM are: locationand hypertrophy degree; identification of obstruction and intraventriculargradient at rest or intentionally caused; presence of magnitude of mitralreflux; systolic and diastolic function; and LA size. Any hypertrophypattern may be found, though the asymmetric is the most frequent one (75% ofcases), and it is more common at the confluence of the anteriorinterventricular septum with the LV free wall.73 Other forms of hypertrophy are: basal,concentric, apical and lateral wall. There is a linear association betweenmaximum myocardial thickness and sudden death, with greater risk in patientswith thickness ≥ 30 mm.74 Gradualidentification of the LV outflow tract is important in the management osymptoms and in the stratification of the risk of sudden death.72 TTE evaluation generallycharacterizes the presence of LV outflow tract obstruction (instantaneousgradient ≥ 30 mmHg) at rest (one third of patients) of afterprovocative maneuvers (one third), such as exercises  or Valsalva maneuver. Echocardiography under physicalstress can be very useful in patients with HCM, since in addition todetecting the presence and degree of obstruction during effort, it allowsthe objective evaluation of symptoms, functional capacity, systolic bloodpressure response and the presence of secondary mitral regurgitation.Approximately 25% of HCM patients have abnormal blood pressure responseduring exercise, characterized by a drop in systolic pressure or by failureto increase in > 20 mmHg. This finding has been interpreted as a riskfactor for unfavorable prognosis and sudden death.75 Stress echocardiography with dobutamine isnot recommended. The cut-off value of the intraventricular gradient ≥50 mmHg at rest or after provocative maneuvers is considered when indicatingsurgical treatment or percutaneous intervention in symptomatic patients,despite therapy with optimized medication.72 Patients with HCM in general havediastolic dysfunction, commonly with altered relaxation (grade I), thoughwithout significant correlation between mitral flow data and LV fillingpressures. Thus, the integrated approach of mitral Doppler data, tissueDoppler, pulmonary vein flow and LA volume is recommended in thesepatients.76 LVEFis normal or increased in most patients, giving the false impression ofpreserved systolic function. However, longitudinal strain assessmentinvariably shows a global and regional decrease (coincident with sites ofgreater hypertrophy) of contractility.77 Estimating the size of the LA is fundamental, asthere is a significant correlation between the dilation of the chamber andan increased risk of cardiovascular events, such as atrial fibrillation andsudden death. The main complication of HCM is sudden cardiac death (SCD),especially in young and apparently healthy individuals.79 Cardiac defibrillator implantation for primary orsecondary prophylaxis may reduce mortality from this complication and is theonly therapy with evidence of life-saving potential.80 TTE has a relevant role inthe two most commonly used risk stratification scores form SCD in HCM, whichdetermined the relationship between come clinical risk factors andprognosis. In the American model of primary prevention, one of the riskfactors among 5 variables is the presence of interventricular septumthickness ≥ 30 mm.75 In the European model, of the seven variables analyzed,three of them are provided by TTE: septum thickness, LA and left ventricularoutflow tract (LVOT) gradient at rest or after Valsalva maneuver.72 Family screening offirst-degree relatives of HCM subjects should be performed periodically dueto their risk of developing the disease. Recommendations for the use ofechocardiography in HCM are summarized in Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular diseasecharacterized by increased left ventricular wall thickness ≥ 15 mm inadults, with non-dilated ventricular cavity not explained by abnormalloading conditions, such as arterial hypertension or valve aorticstenosis.81 Diagnosis byechocardiography is based on common anatomical and functional changes:ventricular cavities of normal or reduced size, usually with Doppler degreeIII diastolic function (restrictive type), generally preserved overallsystolic function, and dilated atria. Tissue Doppler analysis shows velocitye’ obtained in the septal mitral annulus usually below 7.0 cm/s, a usefulmeasure in constrictive pericarditis differentiation.82 In amyloidosis, there isthickening of the atrioventricular valves, myocardial walls, and eventuallythe atrial septum, with a more intense (ecorrefringence) reflection and“granular and sparkling” myocardial aspect.83 The GLS analysis of the LV with 2Dechocardiography in amyloidosis observes very low values, especially in themid and basal segments with relative “apical sparing” .84 In EMF, one may observe: obliteration ofthe apex by fibrosis, signs of ventricular restriction, and involvement ofthe atrioventricular valves. The fibrosis of the apical thrombi isdifferentiated due to absence of akinesia or dyskinesia in the left EMF.Another differential diagnosis is apical HCM, which presents no endocardialthickening or restrictive pattern and displays specific electrocardiographicchanges. Cardiac sarcoidosis may present with regional contractileabnormalities and non-ischemic distribution aneurysms. GLS measurerepresents an early marker of myocardial involvement in sarcoidosis and themagnitude of the reduction is associated with poor prognosis.85 The recommendations forTTE in RCM are set out in Restrictive cardiomyopathies (RCM) are a group of entities characterized byabnormalities in the ventricular filling pattern, which may be associatedwith thickened and rigid walls and generally preserved systolic function.RCMs comprise various entities, including, endomyocardial fibrosis (EMF),endomyocardial fibroelastosis, Löefler parietal endocarditis,infiltrative (such as amyloidosis and sarcoidosis), storage (such ashemochromatosis and Fabry disease), idiopathic and other forms secondary todifferent processes .86 The diseaseis characterized by a progressive replacement of the ventricular myocardiumby fibrous and adipose tissue, which can lead to thinning of the wall andaneurysm formation. In the RV, the process is typically located in theinferior, apical and infundibular walls (dysplasia triangle), and may bediffuse or segmental. LV involvement occurs in more than half of the cases,typically located in the subepicardium or mesocardium, and often confined tothe inferolateral segment. Echocardiography is the imaging modality ofchoice in the initial assessment of AC ; and reductionof the fractional variation of the RV area. Recently, the routine andsystematic addition of other echocardiographic measurements and techniqueswas recommended in order to improve evaluation:89Arrhythmogenic cardiomyopathy (AC) is considered an inherited cardiomyopathywith autosomal dominant transmission, predisposing to the emergence ofventricular arrythmias, sudden death in young people, ventriculardysfunction and heart failure. Due to the frequent involvement of the LV,the use of the term CA is currently recommended, which comprises bothventricles, replacing the term “arrhythmogenic dysplasia of theRV”.nt of AC  and the Conventional parameters: basal RV diameter ; systolic excursion of the annular tricuspid plane .Advanced parameters: wave s’ to the tissue Doppler of the RV’sfree wall ; longitudinal strain of theRV’s free wall ; LV’s GLS ; RV ejection fraction to 3D echocardiography .In short, TTE, preferably with analysis of conventional and advancedparameters, is indicated in patients with suspected or established AC, as well as in family screening offirst-degree relatives.90 it is considered a primary cardiomyopathy, theEuropean Society of Cardiology (ESC)81 considers it an unclassified disorder. Itspathogenesis implies early interruption of compaction of the trabecularmeshwork of the LV during embryogenesis, resulting in the formation of twolayers: a thin compacted epicardial layer and a thick endocardial one(similar to a “spongy” mesh) with marked trabeculations and deepintertrabecular recesses. The 2D echocardiography is the basis fordiagnosis, follow-up, and better delineation of NCC phenotypicexpressions.91Several criteria have been employed in diagnosis, taking into account theincrease in the proportion of the non compacted layer , presence ofexcessive trabeculation, hypokinesia of non compacted areas  and visualization of flow in therecess (via color Doppler). New techniques have recently been incorporatedto aid in diagnosis, such as the use of echocardiographic contrast, 3Dechocardiography and myocardial strain for the analysis of regionaldeformation and rotation .92Therefore, it should be noted that the diagnosis of suspected cases hasincreased in recent years, due to advances and improvements in imagingmethods, as well as the perception of the need to actively investigatefirst-degree relatives affected by the disease (described in 13 to 50% ofthis specific group).93 Onthe other hand, increasingly frequent “exam findings”  have been reported in clinical practice, leading tothe worrisome excess of diagnoses.7 Therefore, it is recommended to carry out acomprehensive evaluation, including clinical, electrocardiographic data andcareful analysis of the findings in complementary imaging studies.94 The recommendations forperforming the echocardiography in NCC are set out in Non-compaction cardiomyopathy (NCC) is considered a distinct cardiomyopathy,marked by genetic heterogeneity, with an overlapping of different phenotypesand great variability of clinical presentation. As a consequence, there isstill controversy in the literature regarding its nomenclature: whereas forthe American Heart Association (AHA)95 Unlikephysiological hypertrophy ,characterized by preserved cardiac structure and function, left ventricularhypertrophy (LVH), secondary to SAH, is commonly associated with fibrosis,myocardial dysfunction and increased mortality.96 The echocardiography is the clinical choiceexam to detect LVH, due to its being more accurate than theelectrocardiogram98 and allowing estimation of LVmass (LVM). The methodology to measure LVM and to define its cut-off points andindex form  varies between studies. Mostechocardiography authors and laboratories follow the recommendations publishedby ASE and EACVI.99 LVM indexing to the bodysurface area in g/m2 is the most used one,100 and normality values are different for menand women , can produce myocardial hypertrophy by increasing ventricularmass.nd women .95,99101 The presence of LVH is considered asevidence of target organ damage in hypertensive patients, and its associationwith cardiovascular diseases and mortality is well documented.104 Such an increase in cardiovascular risk inhypertensive patients is directly related to LVM, regardless of blood pressurevalues.103 Inaddition to LVM, the geometric pattern of LVH is also seen as an importantvariable related to cardiovascular risk. Four patterns of LV geometry99 are described in ,valvular heart disease or other structural cardiac changes, it becomes anessential investigative method , audible at the left sternal border, followed by a second normal sound, inthe absence of other abnormalities.123 This finding, associated with normal chest x-ray andelectrocardiogram, estimates a low probability of cardiac disease and, in thiscase, there is no need for complementary echocardiography.124 However, due to inadequatetraining or maintenance of knowledge, characteristics of the murmur or patient’sanatomy, the auscultation may leave doubts about the existence of underlyingorganic causes. In such situations, the use of electronic stethoscope125 and performing directedcardiac ultrasound,126 ifavailable, may be useful. In case of persisting doubt or suspicion of cardiacalteration, the echocardiography should be performed  or secondary (caused by changes in LV geometry). The 3Dechocardiography is more accurate in volumetric measurements and leftventricular function; it can be useful in the evaluation of RV4 and allows bettervisualization of the valve apparatus and planning ofinterventions.133 The evaluation of theregurgitation degree can be made by the integrated approach of multiplequalitative and quantitative parameters: cavity dilations, pulmonary arterypressure, mitral inflow velocity, pulmonary vein flow pattern, mitralregurgitation density and duration analysis, calculus of the jet area orregurgitant volume, vena contracta measurement andregurgitant orifice measurement .133 Challenging situations for echocardiography arethe presence of multiple and/or eccentric jets, cardiac arrhythmias andacute MR. In these cases, special emphasis should be given to integratedanalysis relating anatomical and hemodynamic parameters. The improvement ofquantitative measures, such as PISA and vena contracta,through the 3D echocardiography, can aid in the evaluation of eccentricreflux.134 Another important pointis the measurement of left ventricular function, especially in asymptomaticpatients, which can be overestimated by LVEF measurement, with implicationsfor deciding the best time for intervention and for postoperative outcomes.Recently, measurement of myocardial deformation (strain) has been studied tomore sensitively identify ventricular dysfunction, but despite goodprospects, it still requires more studies and standardization.136TTE, in addition to diagnostic confirmation, provides information necessaryfor follow-up and decision making in mitral regurgitation(MR).133 The general recommendations for the use of thevarious modalities of echocardiography in MR are contained in TEE, whether 2D or 3D, is indicated for evaluation of the regurgitationmechanism in the care of inappropriate transthoracic images or indiscrepancies between echocardiographic and clinical parameters.137 The hemodynamic characterization of the gradientsand valvular area, together with the description of thickening, leafletmobility, subvalvar involvement and degree of calcification of thecommissures, determines the progression stage of the disease and defines themost appropriate type of treatment when the disease is symptomatic. Thejoint interpretation of the echocardiography and the clinical symptomsdetermines the indication of surgical intervention or balloon cathetervalvuloplasty.137Recently, MS has been grouped into four distinct categories, based onanatomy, Doppler evaluation, presence of pulmonary hypertension,repercussions on LA, and symptoms: stage A (patients at risk for MS); stagesB and C ; and stage D(symptomatic patients with hemodynamic changes). 139 The use of TTE usually defines theanatomy and severity of the lesion  may be usedin the discordance between symptoms and resting echocardiographydata.138 Suchphenomenon of incompatibility between symptoms and hemodynamic repercussioncan result from the disproportion between the valve area and the patient’sbody size, or the lack of complacency of the valve orifice (which shouldincrease during exercise).144 On a low-dose dobutamine echocardiography, the meanmitral transvalvular gradient should increase above 18 mmHg145 in order for MS to beconsidered the cause of the symptoms, while on exercise echocardiography(treadmill), the significant cut-off value is one elevation above 15mmHg.144 The increase in systolicpressure in the pulmonary artery is considered of clinical value only duringthe exercise echocardiography and should reach at least 60 mmHg so thatpulmonary hypertension is considered secondary to MS. Other less frequentindications of a stress echocardiography may be found in asymptomaticpatients with marked stenosis  or lesions on other heart valves.The diagnosis of mitral stenosis (MS) using echocardiography makes itpossible to define its probable etiology as a consequence of a wideevaluation of the valve anatomy.e lesion , but thee lesion .138,140,stenosis .144 Care148 The definition of the moment of surgicalor percutaneous intervention depends on the integrated analysis of clinicaland echocardiographic parameters that allow to classify aortic stenosis into four stages: stage A (risk ofAVS); stage B (mild and moderate asymptomatic AVS); stage C (asymptomaticmarked AVS), subdivided into C1 (with LVEF ≥ 50%) and C2 (LVEF <50%); and stage D .149 In some AVS subgroups,valve area is reduced in the low gradient and low flow periods, either dueto the concomitance of left ventricular dysfunction (LVEF < 50%) or thepresence of small and hypertrophied LV, despite preserved LVEF). Thesesubgroups are designated as stage D2 (with decreased LVEF) or D3 .150 In these discrepancy situations, inwhich valve area is ≤ 1.0 cm2, the gradient is < 40mmHg and LVEF is preserved , additional methods such as TEE ,computed tomography or cardiac resonance may be necessary to confirm theseverity of AVS.147 TEEallows a better evaluation of the aortic valve anatomy , etiology , LV exitpath  and greater accuracy in thecalculation of valvular area, either by continuity equation or by directplanimetry.150 The absence ofsignificant calcification should alert to the possibility of sub- orsupravalvar obstruction. In good-quality images, 3D TTE also allows for amore accurate LVEF assessment and a calculation of ejection volume  by subtraction of final diastolic and systolic volumes,without the need to use LV exit pathway measurement and Doppler. Thiscalculation, however, should be analyzed along with the other parameters,once it may also underestimate aortic transvalvular flow.150 If the calculation of the valve area ismade during hypertension (blood pressure ≥ 140 x 90 mmHg), it shouldbe repeated after blood pressure control because it may underestimate thetransvalvar flow. Reduction in LV systolic function by GLS measurement, withno other explanation, in the presence of preserved LVEF, favors thediagnosis of severe AVS with low paradoxical gradient. Stressechocardiography with low dose of dobutamine, with calculation of theprojected area of the valve, if necessary,147 should be performed if there is marked aortic stenosiswith low-flow/low gradient and left ventricular dysfunction (stage D2) todistinguish truly marked stenosis from pseudostenosis and to evaluate thecontractile reserve , asymptomatic or with mild or doubtful symptoms, to confirm theseverity of AVS using the same criteria.144 In suboptimal images, the evaluation ofLVEF can be improved by the use of myocardial contrast, to better delineateendocardial borders.147The invasive hemodynamic study is restricted to situations in whichnoninvasive imaging tests are inconclusive.149 The follow-up interval with TTE depends on the stageof the disease and predictors of poor prognosis. Accentuated aortic valvecalcification is another predictor of more severe stenosis and worseclinical progression.151Marked AVS with low paradoxal gradient has worse prognosis when compared toclassical AVS and the remaining AVS subgroups.150 The paradoxical low gradient and normalflow (LV > 35 mL/m2) seems to have a prognosis similar to thatof moderate AVS, but should be accompanied by shorter intervals,particularly if symptomatic.147 In classical AVS, the maximum velocity ≥5m/s152 and anannual increase in maximum velocity ≥ 0.3cm/s151 in serial examinations are predictors ofworse prognosis and of faster progression.149TTE is the first-line method  for the  reserve .Echocar reserve . An incr148In patients who are candidates for percutaneous implantation of aorticprosthesis for the treatment of AVS, 3D TEE can be used to evaluate thediameter of the ring, but it depends on the operator and image quality andshould be used only when there is contraindication to computed tomography.On the other hand, 3D TEE is recommended to monitor the procedure and toevaluate outcomes or complications .148153 AR can be observed dueto primary diseases of the aortic valve (AV) or to abnormalities of theaortic root and ascending aorta. Degeneration of AV and bicuspid aorticvalve are the most common etiologies. Other causes include rheumatic fever,fibrosis or infection, alteration of the valvular apparatus support ordilatation of the valve ring. The integrated analysis of clinical andechocardiographic parameters  allows the classification of ARin four stages: stage A (risk of AR), stage B (mild to moderate asymptomaticAR), stage C [asymptomatic acute AR without (C1) or withdysfunction/dilation of LV (C2)]; and stage D (symptomatic acuteAR).149 Insuboptimal images, LVEF measurement may be more accurate with the use ofmyocardial contrast to delineate the endocardial borders.133 TEE (with 3D ifavailable), tomography or cardiac resonance may be necessary to betterassess the aortic root and ascending aorta , the severity of AR, or the quantification of LVejection volumes and ejection fraction.133 The appearance of symptoms in AR drasticallychanges prognosis. Effortless echocardiography may be indicated to revealthe presence of symptoms or to investigate other causes not related to AR.144 However, it should notbe used to assess severity, once that increased heart rate shortensdiastole, limiting quantification.144 The follow-up interval with TTE depends on thestage of the disease and the presence of aortic dilatation associated withbicuspid aortic valvopathy.154Recommendations for the use of the various modalities of echocardiography inAR are set out in Echocardiography is the first-choice method to confirm diagnosis and etiologyand to assess the severity and hemodynamic consequences of aorticregurgitation (AR).149 In most cases, tricuspid regurgitation (TR) issecondary to tricuspid ring dilatation and leaflet pull due to distortionand right ventricular remodeling, which occur due to volume or pressureoverload caused by diseases of the left side of the heart , pulmonaryhypertension, pulmonary valve stenosis, among others. In this context,leaflets are structurally normal. Primary causes of TR are rarer and may bedue to infective endocarditis (mainly drug users), rheumatic heart disease,carcinoid syndrome, myxomatous disease, endomyocardial fibrosis, cornealrupture related to endomyocardial biopsy, Ebstein’s anomaly, and congenitaldysplasia, among others.133 Similar to mitral and aortic valve disease, it can beclassified into four stages (A to D).149 A thorough analysis of valvular anatomy by TTE isfundamental for the diagnosis of the etiology and mechanisms involved. It isnecessary to measure the diameter of the ring and the use of all indexes ofRV systolic size and function.133 These measures help in decision making regardingthe moment of the surgery and in the surgical planning. In situations ofdoubt regarding the RV, 3D TTE can be used, although it still requires morevalidation. Cardiac resonance remains the gold standard.146 In this context, TEE isnot recommended due to the anterior location of the RV, which makes itdifficult to see through the transesophageal route.148 Significant primaryTR requires intervention before RV impairment.149 Secondary TR is usually treated when left side valvedisease is corrected. As in the other valvopathies, the echocardiographicfollow-up interval depends on the stage of the disease, but the etiology ofthe disease must also be considered. In the case of secondary TR, it isappropriate to follow the recommendations described for left heart valvedysfunctions. Significant annular dilatation (≥ 40 or > 21mm/m2) and dilatation or progressive RV dysfunction shouldalert for earlier follow-up.133 Tricuspid stenosis (TS) is an uncommon condition that,if present, is frequently associated with TR of rheumatic origin.149 In this case, the presence of associatedmitral stenosis is common, which is usually the predominant lesion. Othercauses are rare, such as congenital diseases, drugs, Whipple’s disease,endocarditis, and large right atrial tumor.146 TS diagnosis of is often neglected.Careful analysis of the subvalvular apparatus is essential to predict valverepair.146 Theintegration of clinical and echocardiographic parameters related to TS  classifies severity in stages C(marked asymptomatic) and D (marked symptomatic).149TTE is the first-line method for evaluating tricuspid valve abnormalities.146,148,149 In addition to assessing the valvularanatomy, investigation of the etiology requires a thorough evaluation of theRV, pulmonary ring, pulmonary artery trunk and its branches. Primary PS orPR (with leaflet involvement) are more often due to congenital diseases thanacquired ones. Secondary PR occurs in situations of pulmonary hypertension.There is little literature on the quantification of the severity of PR onthe echocardiography, but there is a consensus that it should be done in anintegrated way with pulsed, continuous and color Doppler parameters; andgraded as mild, moderate, or marked.133 PS and PR are classified, from theclinical-echocardiographic point of view, as stage C (marked asymptomatic)and D (marked symptomatic).149 Evaluation of the pulmonary valve may be difficult forTTE. In this situation, however, the TEE does not provide additionalinformation and is not recommended (class III). There is little data on thevalue of 3D echocardiography. In cases of limited transthoracic imaging orseverity parameters inconclusive or discordant with clinical data, cardiacresonance is recommended as the best method.133TTE is the initial recommended method to diagnose and evaluate the severityof pulmonary stenosis (PS) or regurgitation (PR), its etiology and effectson cardiac structure and right ventricular function (class I).141 Inthe EuroHeart Survey, 51% of AVL patients had RF and 40% had degenerativevalve disease.155Pathophysiology is complex, because it depends on the specific combinationof each valve lesion, and its diagnosis is challenging because theguidelines provide us with specific valvular parameters alone. AVL mayresult from two primary valvular diseases156 or from the combination of primary andsecondary valvular disease.157 Despite the high prevalence of AVL, there is littleevidence of the best course of action to be taken in each combination. Themost common combinations and their most frequent changes are reportedbelow:156Associated valvular lesions (AVL) in our setting are frequent due to the highprevalence of rheumatic fever (RF), which reaches 70% of valvular heartdisease in Brazil.158 In some AScases, there may be MR secondary to dilation and leftventricular dysfunction (tethering). Less frequent, but possiblein these patients, is the presence of primary MR.AS and MI: Increased LV pressure caused by aortic stenosis mayincrease the regurgitant orifice and decrease aortictransvalvular gradients, mimicking a low-flow state.156AS and MS: are cases of difficult clinical control, in which thepatient rapidly evolves to low throughput states. The gradientsof both valves may be underestimated, and if the patient isinadvertently submitted to balloon catheter valvotomy of themitral valve, acute pulmonary edema may occur due to the lack ofLV compliance as a consequence of AS.156AR and MS: the presence of MS limits the increase in ventricularvolumes frequently observed in AR; which may underestimate theseverity of AR.158MR and AR: as a consequence of the volume overload imposed byboth valvopathies, these patients usually have earliercontractile deficit than with each isolated valvopathy andprogress more rapidly to the symptomatic phase of thedisease.156 Inthe case of balanced lesions, TTE should be repeated with a shorter intervalthan the one suggested for a single valve lesion.156Recommendations for TTE and TEE in AVL are listed in 159 or ten years(ACC/AHA) are recommended).127 However, annual examinations are recommended in patientswith new design prostheses that have not had their proven durability in patientswith aortic dilatation at the time of surgery and in patients with mitralprostheses to evaluate the evolution of tricuspid regurgitation and RV function.Echocardiographic investigation (TTE and TEE) is recommended when changes incardiac auscultation, onset of symptoms or suspicion of prosthesis dysfunctionoccur. In cases where there is clinical suspicion of infective endocarditis orthrombosis, the analysis should be more thorough.123 In cases of significant reflux ofprostheses, it is recommended to perform evolutionary TTEs every three to sixmonths.128 TEE, dueto its proximity and posterior approach to the heart, achieves better diagnosticprecision in valvular prosthesis dysfunctions. In fact, TTE and TEE complementeach other, since the TTE better evaluates the changes in flow and TEE, themorphological changes. It is always advisable to carry out the full and carefulTTE before recommending the TEE. The 3D TEE160 provides additional information about the 2D image,particularly regarding the spatial relationship of the structures around theprosthesis, the direction and extent of regurgitant jets, the location ofparavalvular leaking and the identification, position and number of largeranomalous prosthetic or periprosthetic echoes, potentially moreembolinogenic.161 Thediagnosis of prosthesis stenosis should always be performed with the extensiveuse of echocardiography. The transprosthetic gradients are variable in eachmodel and size, and there may be high gradients in cases of small, even normal,prostheses when implanted in large body surface patients, a finding known asmismatch.162 Patientswho remain with significant LVH in the late postoperative period may alsopresent elevated gradients after aortic prosthesis implantation. Thus, thecomparison with the basal echocardiography is always important. In biologicalprostheses, the most frequent cause of stenosis is the degeneration andcalcification of the leaflets, usually a late complication. In mechanicalprostheses, the growth of fibrous tissue into the ring, known as pannus, is alsoa late complication that can cause stenosis, reflux, or double prostheticdysfunction. The detection and quantification of the reflux of the prosthesesare usually hampered by the acoustic shadow caused by the mechanical prostheses,mainly in the mitral position. In such cases, TEE can aid in the detection andquantification, and determine if the insufficiency is prosthetic orperiprosthetic, functional or pathological. We must be careful indifferentiating the “physiological” refluxes, which are common in prostheses,from the pathological ones.163 In general, physiological reflux presents laminar flow atcolor Doppler and pathological reflux presents a turbulent, color mosaic flow.In cases of suspicion of infective endocarditis in prosthetics, the diagnosis ismade difficult by the presence of shadows and reverberations, allowing the TTEto identify only the large vegetation. Given the clinical suspicion ofendocarditis, it is always advisable to perform the TEE, which has greatersensitivity, detecting smaller vegetations and possible complications, such asannular abscesses  and new valve regurgitation.169Infective endocarditis (IE) is vascular or cardiac endocardial infectionresulting from invasion of microorganisms. Despite the advances in diagnostictechniques and treatment, mortality by IE remains high.approach .165-168 170 Regardless of the mechanism, it is defined as meanpulmonary arterial pressure greater than or equal to 25 mmHg, at rest, documented bycardiac catheterization.170Currently, TTE is considered a method of fundamental importance in the initialevaluation of patients with clinical suspicion of PH , can bemeasured by this method.172 Thepresence of RV hypertrophy, enlargement of the right cavities, anomalous movement ofthe septum and pericardial effusion suggest the diagnosis. The analysis of thecontractile function of the RV is performed through the TAPSE, s-wave (systolic) ofthe tissue Doppler, RV area fractional variation and ejection fraction to the3D.4 Right cardiaccatheterization remains the gold standard for diagnosis, since it allows the directmeasurement of hemodynamic data in the pulmonary circulation and evaluates thecapacity of response to vasodilator therapy through the pulmonary vasoreactivitytest.Pulmonary hypertension (PH) is a clinical condition associated with high morbidityand mortality, the prevalence of which is unknown due to different presentationgroups. From the knowledge of the various pathophysiological mechanisms, the currentclassification divides PH into five groups.on of PH , since i170 Clinicalsuspicion, progress in diagnosis, and effective therapy are critical in reducingmortality in the acute event. The sensitivity and specificity of TTE for thediagnosis of PTE are 50 to 60% and 80 to 90%, respectively. In critical patients,TEE may increase this sensitivity. The visualization of the thrombus in the rightatrium (RA), in the RV or in the trunk of the pulmonary artery ratifies thediagnosis. However, indirect signs are more commonly found, such as dilatation ofthe right cavities, RV contractile dysfunction, interventricular septal flattening,McConnel’s signal  and dilation of theinferior vena cava. The pulmonary artery acceleration time is a parameter with goodsensitivity, since it is altered (< 100 ms) in cases of small pulmonaryembolism.173 RV strain is an important tool because it shows the segment thatpresents reduced value and evaluates its deformity after reperfusion therapy.Patients who develop contractile dysfunction of the RV or patent foramen ovalepresent a reserved prognosis.Pulmonary thromboembolism (PTE) is another clinical condition of high mortality,which can cause complications such as chronic thromboembolic pulmonary hypertension(PH group IV).175 long-termstable angina or acute coronary syndrome (ACS)/acute myocardial infarction (AMI)with hemodynamic instability as the first manifestation of thedisease.177 The echocardiography hasapplications in its diagnostic recognition, stratification of risk in the acutephase, follow-up and determination prognosis in the long term.179Coronary artery disease has a wide clinical spectrum, ranging from asymptomaticsevere disease,180 Evidence of new or presumablycontractile change from LV to TTE is one of the parameters in the thirduniversal definition of myocardial infarction181 and may in fact assist in thediagnosis/prognostic determination of an ACS. In addition, TTE may aid inthe differential diagnosis of chest pain and/or associated conditions, suchas acute aortic dissection, aortic stenosis, hypertrophic cardiomyopathy,and pulmonary embolism.180 By dividing LV into 16 or 17 segments, contractilesegmental function is visually quantified based on systolic thickening (ST):hyperkinetic = 0 (ST > 70%); normal = 1 (ST = 50 to 70%); hypokinetic = 2(ST < 40%); akinetic = 3 (ST < 10%); “dyskinetic = 4 ”. The wall motion score index (WMSI) is thereference parameter to express the LV segmental function and its normalityvalue is 1; values between 1 and 1.6 show a contractile alteration of milddegree; while WMSI values above 1.6 indicate greater involvement and worseprognosis.182Obviously, the absence of alterations in segmental contractility in restingTTE does not exclude the presence of coronary artery disease.180 It should also beconsidered that the contractile alteration may occur in other conditionssuch as myocarditis, RV overload (volume/pressure), ventricularpre-excitation, Takotsubo type cardiomyopathy, left bundle branch block,chagasic cardiomyopathy or presence of pacemaker.180 TTE is the exam of choice in cases ofhemodynamic instability with suspected cardiac origin, as well as in theidentification of mechanical complications of AMI.180 However, it is necessary to avoid requesting theexamination for evaluation of patients with chest pain with a confirmeddiagnosis of myocardial ischemia (ACS/AMI), since TTE should not delay theimmediate onset of treatment.180 On the other hand, inthe screening of symptomatic patients suspected of having coronary arterydisease in the emergency room, recent evidence indicates the potentialusefulness of GLS calculated by 2D speckle tracking. In the absence ofpreexisting structural heart disease, previous infarction or left bundlebranch block, GLS (when < 16.5%) may complement existing diagnosticalgorithms and act as an early adjunct marker of ischemia.183In the scenario of a patient with acute chest pain and suspected coronaryartery disease, echocardiography may be useful  and shou184 Stress echocardiography is an independent predictor ofcardiovascular death, of additional value to the other methods and can avoidcoronary angiography.179 Its use may berecommended for risk stratification of patients in chest pain units suggests ischemic etiology.in units , especia180 In patients with acute chest pain andnon-diagnostic electrocardiogram, the use of contrast echocardiographyincreases sensitivity for the diagnosis of ACS  or cardiomyopathies that may occur with chestpain; the second is based on the knowledge of global left ventricularfunction as a prognostic factor in stable patients with chronic coronarydisease  causes account for 30 to 40% of these ischemicneurological events.204 Other causes of ischemic strokeinclude large artery atherosclerosis, small vessel occlusion (lacunar), and otheretiologies.205 Inpatients who are at risk or who have already had embolic neurologic events, the mainrole of echocardiography is to identify the presence of an emboligenic source, todetermine the probability of such a source being a possible cause of ischemic strokeor systemic embolism and to guide the therapy of these patients. We can classifycardiac diseases as for their emboligenic potential under high and low riskconditions ;207 mechanicalvalvular prostheses ;208 and infectious endocarditis (onein five cases are complicated by ischemic stroke).209 Variable rates of annual recurrence of ischemicstroke have been reported in patients with aortic arch atheroma (less than 3 to12%).210 The patentforamen ovale (PFO) can serve as a passageway from a paradoxical embolism of thevenous to the arterial circulation. Although patients with an ischemic stroke ofindeterminate (cryptogenic) etiology have a higher incidence of FOP than those withknown ischemic stroke cause,211 alarge study reported that the presence of a PFO was not associated with an increasedrisk of recurrence of ischemic stroke.212 Other more rare causes of embolism include papillaryfibroelastoma, myxoma, and mitral calcification.Stroke is the major cause of disability and the second leading cause of death in theworld.nditions . The mai213 Systemicembolization to other organs such as spleen and kidneys at the time of the ischemicstroke increases the suspicion of cardioembolic etiology.213 TTE and/or TEE should be recommended in patientswith suspected cardiac embolic source, including ischemic stroke and transientischemic attack (TIA) or systemic embolism. TTE is more suitable for evaluation ofembolic sources present in previous cardiac structures, such as the apical thrombusinvestigation of the left ventricle. In contrast, during the TEE, the transducer ispositioned in the esophagus, and the probe is closer to the posterior heartstructures. The esophagus is also adjacent to the LA, so TEE corresponds to the goldstandard examination for thrombus screening in the left atrial appendix, withsensitivity and specificity approaching 99%. TEE should be recommended as an initialdiagnostic tool in the assessment of cardiac embolic source in patients withischemic stroke, especially in those where the therapeutic decision (anticoagulationor cardioversion) will depend on the echocardiographic findings. TEE should also berecommended when TTE imaging is of poor quality in young patients with ischemicstroke, in patients with ischemic stroke of undetermined etiology, and in those withnon-lacunar ischemic stroke. TTE may not be useful when TEE is already programmedfor TEE, such as in the evaluation of intracardiac masses, prosthetic heart valves,the thoracic aorta, or to guide percutaneous procedures. TEE should not berecommended when TTE findings are compatible with the embolic cardiac source. BothTTE and TEE should not be recommended in patients whose results will not guide thetherapeutic decision. The cardioembolic etiology of ischemic stroke should be suspected in the presence ofsevere onset of early neurologic deficit without prodromes, multiple brain lesionsin multiple vascular territories, and recurrent ischemic stroke in a short period oftime.215 In the UnitedStates, it is estimated that the prevalence of atrial fibrillation will double from5.2 million cases in 2010 to 12.1 million cases in 2030.216 In addition to population aging, the increasedprevalence of AF can be explained by the comorbidities and associated cardiovascularrisks such as hypertension, heart failure, coronary artery disease, valve diseases,obesity and diabetes mellitus.217The risk of developing AF is 1 in 4 individuals from 40 years of age on.218 Recent national andinternational guidelines have reported the classification of AF based on itspresentation, duration and spontaneous termination of AF episodes.220 Paroxysmal AFis defined as that which is reversed spontaneously or with medical interventionuntil seven days after its initiation. Episodes lasting longer than seven days arereferred to as persistent AF. Persistent long-term AF represents cases lasting morethan one year. Permanent AF corresponds to the cases in which attempts to revert tosinus rhythm will no longer be instituted. Finally, non-valvular AF is defined as AFin the absence of rheumatic MS, mechanical or biological valve or previous mitralvalve repair. As part of the initial evaluation, all AF patients should have a TTEto identify structural heart diseases, including valvular heart disease, assess RAand LA size, LV and RV size and function.184 TEE is the most sensitive and specific technique fordetecting intracavitary thrombi, especially in the left atrial appendage, as apotential source of systemic embolism in AF, and can be used to guide earlycardioversion or catheter ablation procedures.221 TEE can also identify featuresassociated with an increased risk of thrombus formation in LA, including reducedflow velocity in the left atrial appendage, spontaneous contrast in LA, and aorticatheroma.214222 New echocardiographictechniques such as LA evaluation by strain and 3D echocardiography are promisingtools for future clinical practice.222Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, whoseprevalence increases with advancing age.223 Cardiac tumors are extremely rare, withsecondary tumors (metastatic neoplasms) being 20 times more frequent than primarytumors.225 Although the classification ofthese lesions for benignity or malignancy is an important predictor of prognosis,any cardiac tumor may have substantial hemodynamic or electrical consequencesdepending on size and location.226 Most are detected incidentally during cardiac imaging tests orafter complementary evaluation of specific clinical situations, such as afterembolic event, suspected endocarditis and the possibility of malignancy involvingthe heart. Myxomas are the most frequent benign primary tumors in adults, followedby fibroelastomas and, finally, fibromas (much more common in the pediatricpopulation). Primary malignant tumors, however, represent a much smaller portion ofprimary cardiac neoplasms, with sarcomas and lymphomas being more common. Much morefrequent, as mentioned above, are secondary tumors, represented by metastases, whichcan occur by various forms of dissemination , associated mainly to tumors of the breast, lung, esophagus, mediastinumand melanoma. In these cases, the involvement of the pericardium occurs most of thetime.227The cardiac masses comprise a broad set of lesions which may be neoplastic andnon-neoplastic in nature. As regards incidence, the most frequent causes of cardiacmasses are thrombi and vegetation, and rarely are tumors and pseudotumors (intrinsicand extrinsic structures that mimic a cardiac tumor).229 The contrasted echocardiographicstudy represents a very useful tool, offering greater anatomical detail andassisting in the differentiation of the masses through the analysis of itsvascularization .230Echocardiography, because of its availability and applicability, is the imagingtechnique commonly chosen for diagnosis . The exa232 It contributes decisively to thesemiquantitative evaluation of the pericardial effusion and its hemodynamicrepercussion (depending on the volume and the velocity of the collected fluid), aswell as exploring the underlying etiology, whether primary  or secondary .The method provides information about the nature of the fluid, suggesting thepresence of fibrin, clot, tumor, air, and calcium. The size of the effusion may beclassified by the diastolic measurement of the echo-free pericardial space , as ofsmall (< 10 mm), moderate (10 to 20 mm) and large (> 20 mm).233 Findings indicative of cardiaccompression may precede the clinical manifestations of the tamponade and configurean emergency situation. In this context, pericardial puncture guided byechocardiography may alleviate hemodynamic impairment and save lives.233 Such procedure can be performedsafely in centers with experience, avoiding radiation associated with fluoroscopyand/or cost of surgery, which makes pericardiocentesis guided by echocardiographythe procedure of choice.234Individuals with chronic or recurrent pericardial effusion, not responsive to theproposed clinical treatment, may be referred for elective pericardial drainage afterserial evaluation. The spectrum of echocardiography utilization in pericardialdisease also includes congenital defects, trauma, neoplasia, cysts, CT afterradiotherapy and the differential diagnosis between constrictive pericarditis andrestrictive cardiomyopathy. In this differentiation, findings compatible withconstriction are: exacerbated decrease (> 25%) in the E-wave velocity of themitral flow in the first beat after inspiration, normal tissue Doppler mitralannular velocity (e’ > 7 cm/s) and annulus paradoxus .233Echocardiography should be indicated in the suspicion of pericardial affections,including (but not only) pericardial effusion, pericardial mass, constrictivepericarditis, effusive-constrictive pericarditis, patients after cardiac surgery andsuspicion of cardiac tamponade .231,232 235 For example, examination ismandatory in individuals with systemic diseases potentially causing restrictivecardiomyopathy that show signs and symptoms of heart failure in clinicalevolution. Some systemic diseases for which the indication of the examinationshould be considered are as follows.The indication of echocardiography in systemic diseases depends on the prevalenceof associated heart disease, the characteristics peculiar to cardiac involvementin each situation and the clinical suspicion of cardiac involvement.238 International guidelinesrecommend TTE for all dialysis patients one to three months after the initiationof renal replacement therapy and at three-year intervals thereafter, despite thesymptoms.239Morphophysiological changes in LV  are common in patients with end-stage renal disease andpredict a worse prognosis.240It is a common cause of restrictive cardiomyopathy and may be familial(transthyretin) or nonfamiliar (primary or light chain). Cardiac involvement dueto amyloid deposition may lead to some suggestive echocardiographic findings:thickening and increased echogenicity (“granular” appearance) of the LV walls, biatrial dilatation,thickening of the valves and interatrial septum, diastolic dysfunction (grade IIand III), small pericardial effusion, prominent decrease in longitudinal strainin the basal and mid LV segments , and latersystolic dysfunction with LVEF.241It is important to investigate the presence of cardiac involvement in sarcoidosis(granulomatous disease of unknown origin), as this is a potentially fatalcondition. Among the various echocardiographic findings that may be found, wehave: dilated cardiomyopathy, restrictive cardiomyopathy, segmentalcontractility alterations that do not obey the classic coronary territorialdistribution, basal septum akinesia, inferolateral aneurysm and abnormalthickness of the septum (thickening or thinning).242The echocardiography can detect silent pericardial metastases in some types ofneoplasia (such as breast and lung) and monitor the cardiotoxic effect ofchemotherapeutic agents.235The test may diagnose lupus-associated cardiac manifestations, such aspericardial effusion and sterile vegetations, systemic sclerosis, such aspulmonary hypertension, or rheumatoid arthritis, such as valveabnormalities.243However, the TTE should be considered a screening test, with limitations, sinceit does not allow the analysis of all segments of the aorta, such as the aorticarch and the distal descending. In this case, it is necessary to use otherimaging methods such as TEE, computed tomography or magnetic resonanceimaging.243 The TEE allows therealization of excellent resolution images due to the proximity of the esophagusto the thoracic aorta. Despite the multiplanar sections offered, a small segmentof the ascending aortic junction with the aortic arch is not visualized due tothe interposition of the trachea.154 The precise diagnosis of acute aortic syndromes, suchas aortic dissection, intramural hematoma, penetrating ulcer and rupture ofaortic aneurysms, is fundamental in the therapeutic strategy to be adopted. Inunstable patients with suspected acute aortic syndrome, the imaging modalitychosen will depend on local availability and expertise. In general, TTE isperformed as an initial investigation (class I), complemented with TEE and/ortomography (both class I). The TEE shows good accuracy, mainly in the exclusionof artifacts caused by reverberations of the anterior wall of the LA and thepulmonary artery.244Depending on the clinical suspicion, the diagnostic investigation should proceedwith two or more imaging examinations due to the possibility of falsenegatives.245The evaluation of the aorta is routine in the TTE, since it allows to examinesome of its segments, mainly the aortic root and the proximal portion of theascending aorta, affected in numerous affections. The root of the aorta isformed by the aortic ring, the sinuses of Valsalva and the synotubular junction.The descending aorta and the proximal abdominal aorta can be evaluated at thesuprasternal and subxiphoid sections, respectively.The trunk of the pulmonary artery and the initial portion of the pulmonarybranches can be assessed to TTE. TEE is more accurate, allowing a greaterexamination of the pulmonary artery and its branches, which allows a betterappreciation of thrombi in the proximal territory of the pulmonary artery.Dilations of these vessels can also be diagnosed. Pulmonary artery dilatationsare uncommon lesions and may be associated with different etiologies, such ascongenital heart diseases, systemic vasculitis, collagenosis, infections andtraumas.246Anomalies of the superior and inferior vena cava can be diagnosed by TTE and/orTEE. The presence of thrombi in these pathways and the extension of tumors intothe right cavities can be evaluated. TEE is particularly useful for theidentification of thrombus or vegetation in the superior vena cava in patientswith long-stay catheters and in cases of pulmonary vein stenosis after AF oratrial flutter ablation procedures. The persistence of the left superior venacava should be suspected in the presence of dilated coronary sinus and thediagnosis can be made using intravenous injection of agitated saline solution,which will first contrast the coronary sinus and then the right cavities. Inthis case, it is important to emphasize the need to exclude anomalous drainageof the left pulmonary vein via the vertical vein.248 In non-cardiac surgeries,clinical information obtained by intraoperative echocardiography is oftencomplementary to data provided by other hemodynamic monitoring devices .249 In the case of cardiovascular surgeries, theintraoperative echocardiography can also contribute with real-time dynamicinformation and images of the cardiac structures to plan, guide and evaluate theimmediate result of the surgical intervention.250Intraoperative echocardiography is a technique for monitoring cardiac andnon-cardiac surgeries that allows a rapid and real-time assessment of anatomicand functional cardiac features , aortic and phenomena with embolicpotential.248Transesophageal: most widely used in open, minimally invasive orpercutaneous cardiac surgeries, as well as in non-cardiac surgeries.It has the advantage of not entering the sterile field and of notdisturbing the surgical procedure, allowing continuous monitoring.It is a relatively safe modality when performed by properly trainedprofessionals. The contraindications are the same as for theconventional TEE. In young children, the use of intraoperative TEEshould be considered on a case-by-case basis, based on the uniquerisks of these patients .249Epicardial or epiaortic: are an alternative for monitoring open heartsurgeries in which there is absolute or relative contraindication ofmanipulation of the esophagus, or blood dyscrasia. In theseembodiments, the linear or sectoral transducer is wrapped in asterile cap and applied directly over the heart or aorta. Theepiaortic technique is a very important tool in patients withadvanced atheromatous disease, since it allows the choice of asuitable site for cannulation and aortic clamping.Transthoracic: may be considered as a monitoring alternative forpercutaneous or non-cardiac procedures that are performed withsuperficial sedation, or in cases in which the patient has absoluteor relative contraindication of esophageal manipulation. In thismodality, the examination can be performed serially during theprocedure, or at specific times as needed .Intracavitary: little used, more restricted to percutaneousprocedures.249 The main recommendations inthis scenario are in the The main objectives of the use of intraoperative echocardiography in cardiac andthoracic aorta surgeries are: to confirm and refine the preoperative diagnosis;to detect new or unsuspected morphophysiological alteration; adjusting thesurgical or anesthetic plane according to the findings; to guide the positioningof cannulae or devices; to evaluate the presence of air, masses and thrombi incardiac cavities and their embolic potential; to evaluate segmental and globalleft ventricular function and cavitary pressures; and to evaluate the immediateoutcome of the intervention.249 The main recommendations inthis scenario are found in The main objectives of intraoperative echocardiography in non-cardiac surgeriesare: to assess volume status and fluid response; to estimate vascular resistanceand cavitary pressures; to evaluate function of the ventricles  and valves; and to investigate special issues according to theclinical status and the type of intervention.234 In some examinations, it becomes necessaryas well as essential, since the X-ray (XR) image is insufficient to perform theprocedure, and sometimes even expendable. The role of echocardiography in majorinterventional procedures follows below.In general, cardiac interventions through cardiac catheterization have developedwith the support of the echocardiographic image, especially by thetransesophageal route. Its use in daily practice is increasingly frequent, inview of the development of techniques and technologies for the treatment ofdiseases previously only corrected by the conventional surgical procedure. Inaddition, there was remarkable progress in the diagnostic capacity ofechocardiography, mainly due to the improvement of the image quality and theadvent of the 3D image, obtained by TTE and TEE. The examination has practicallyno contraindication and allows the early identification of potentialcomplications. There is no randomized study for non-use of echocardiographyduring procedures, and some are limited to the use of thoracic, esophageal orintracardiac modalities. Therefore, in relation to interventional procedures,indication of echocardiography use is in principle class I, level of evidence C,a fact already recognized in the literature.Atrial septostomy: also known as Rashkind procedure. The septostomyis performed by balloon in a population in which the TTE allows anoptimal visualization of the atrial septum and of the catheter,guiding in an appropriate way and evaluating the immediate resultand eventual complications. The use of TEE is usually unnecessary,and also impracticable, due to the lack of adequate probes. In thiscase, even the XR scoping can be discarded.251Procedures for occlusion of atrial septal defects: there are devicesfor occlusion of defects of the atrial septal defect, ostiumsecundum, as well as patent foramen ovale. The examination can beperformed in both, mainly TEE or intracardiac echocardiography,where it is possible to assist in the choice of the device, itspositioning, immediate result and rapid identification ofcomplications. TTE may be preferable to TEE in selectedpatients.Procedures for occlusion of ventricular septal defects: TEE should beperformed to better understand the anatomical aspects, the procedureitself and possible complications. Acquired ventricular septumdefects, such as those after trauma or after acute infarction, mayalso be treated with the aid of echocardiography, presenting thesame value in the procedure.Procedures for occlusion of ductus arteriosus persistence: in thissituation, echocardiography is disregarded, since catheterizationduring the procedure is usually sufficient for success.The echocardiography mainly supports the procedure of puncture of the atrialseptum, usually through TEE, or alternatively by intracardiac echocardiography.In the procedure of ablation or implantation of pacemaker the echocardiographyis dispensable, since the electrical mapping provides the necessary information.In the presence of complications, such as perforation of a chamber withpericardial effusion and tamponade, the echocardiography is normallyrequested.One of the treatments for symptomatic patients consists of alcohol ablation ofthe segment where there is a greater degree of hypertrophy and related tointraventricular obstruction in its exit pathway. TTE is more used, and there isno restriction on the use of TEE. Prior to alcohol infusion, the septal arteryis catheterized and a solution is infused. At this time, the echocardiographyshould assess whether the contrast-enhanced myocardial segment corresponds tothe portion of the myocardium associated with the obstruction and if it does notoccur in all transmurality of the segment, which is undesirable. The Dopplerstudy estimates the gradient of obstruction and also the degree of mitralregurgitation. After alcoholic ablation, we repeat the measurement of gradientsand mitral regurgitation, whose falls indicate successful treatment, andpossible complications are investigated.An alternative, when it is impossible to carry out adequate anticoagulation inpatients at high risk for atrial arrhythmia embolism, is occlusion of the leftatrial appendage. TEE is mandatory in this treatment the, as it not only helpsthe transseptal puncture, but also allows adequate appenddage measurements,which select the dimensions of the occluder device. Still in the room, the TEEguides the procedure, confers its result and makes it possible to diagnosecomplications.Percutaneous treatment of mitral regurgitation: among the severaltreatments proposed, the only one that is commercially available isMitraclip®. In this treatment there is a mimicry of theAlfieri surgery, where there is the formation of a double mitralorifice. To do so, a metallic clip is inserted through the vein,which advances to the LA after puncture of the atrial septum and ispositioned so as to reduce severe mitral regurgitation. In thiscase, no step is performed without the TEE, considering that the 3Dimage provides better understanding of the procedure.253 In the intervention, the TEE is preferable,and the morphological aspects of the mitral valve should bereviewed. During the inflation of the balloon , theechocardiography allows to detect proper positioning. Immediatelyafter the procedure, measures are performed with the objective ofevaluating the success of the procedure and the complications thatmay have occurred.Balloon catheter mitral valvotomy: the use of balloons for thetreatment of severe rheumatic mitral stenosis is a safe andefficient alternative. The echocardiography prior to the procedureprovides information that can predict the chance ofsuccess.Balloon catheter aortic valvotomy: the use of this therapy iscurrently safeguarded as the last alternative for the treatment ofaortic stenosis or as a bridge to compensate for the clinicalcondition and subsequent implantation of a prosthesis via cardiaccatheterization or surgery. The echocardiography can be used toevaluate immediate results and complications.254 Whether femoralor transapical, monitoring of the arrival of the prosthesis to theaortic valve is performed, as well as the aid of the idealpositioning, prior to its opening. After implantation, the TEEshould provide data on adequate prosthesis expansion, presence anddegree of prosthetic and/or paraprosthetic regurgitation.Complications of the procedure are part of the echocardiographyinvestigation.Transcatheter implant of aortic valve prosthesis: the indication ofthe percutaneous implantation of aortic valve prosthesis isconditioned to clinical and morphological aspects of the aorticvalve. It is necessary to diagnose severe aortic stenosis prior tothe procedure, as well as the analysis of the aortic complex, whichselects the size of the most appropriate device for the procedure,directly related to its success. The preference is for the use ofTEE, especially with 3D image. During the procedure, it is necessaryto review the severity of valve stenosis by measuring the gradientsand estimating the effective flow orifice. Still, measurement of theaortic complex and especially of the area/perimeter of the aorticring, performed only through the 3D echocardiography is necessary.The value obtained is optimally related to tomography measurementsthat are usually used to select the device.Valve in valve: The term “valve in valve” means the implant of aprosthesis via a catheter over a dysfunctioning bioprosthesis. Itcan be made in prostheses in aortic and mitral position, the latteronly by transapical way. The monitoring during the process ofarrival of the prosthesis, its implant and the identification ofcomplications must be done by the TEE.Occlusion of paraprosthetic regurgitation orifices: one of thepossibilities of regurgitation in a valve prosthesis is the presenceof paraprosthetic orifices. TEE, especially 3D, should be used toidentify these orifices, locate them accurately, and measure theirarea and diameter to select the most appropriate occlusion device.In the procedure, the echocardiographic image helps to visualize thepassage of the guiding catheters through the paraprosthetic site, toopen the device and to measure the success of the treatment.