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ACC/AHA GUIDELINE

ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article

a report of the American college of cardiology/American heart association task force on practice guidelines (ACC/AHA/ASE committee to update the 1997 guidelines for the clinical application of echocardiography)

Melvin D. Cheitlin, MD, MACC, Chair, William F. Armstrong, MD, FACC, FAHA, Gerard P. Aurigemma, MD, FACC, FAHA, George A. Beller, MD, FACC, FAHA, Fredrick Z. Bierman, MD, FACC, Jack L. Davis, MD, FACC, Pamela S. Douglas, MD, FACC, FAHA, FASE, David P. Faxon, MD, FACC, FAHA, Linda D. Gillam, MD, FACC, FAHA, Thomas R. Kimball, MD, FACC, William G. Kussmaul, MD, FACC, Alan S. Pearlman, MD, FACC, FAHA, FASE, John T. Philbrick, MD, FACP, Harry Rakowski, MD, FACC, FASE, Daniel M. Thys, MD, FACC, FAHA, Elliott M. Antman, MD, FACC, FAHA, Chair, Sidney C. Smith, Jr, MD, FACC,FAHA, Vice-Chair, Joseph S. Alpert, MD, FACC, FAHA, Gabriel Gregoratos, MD, FACC,FAHA, Jeffrey L. Anderson, MD, FACC, Loren F. Hiratzka, MD, FACC, FAHA, David P. Faxon, MD, FACC, FAHA, Sharon Ann Hunt, MD, FACC, FAHA, Valentin Fuster, MD, PhD, FACC,FAHA, Alice K. Jacobs, MD, FACC, FAHA, Raymond J. Gibbons, MD, FACC,FAHA^* and Richard O. Russell, MD, FACC,FAHA

Key Words: ACC/AHA Guidelines • echocardiography • imaging

	I. General considerations and scope

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

Each section has been reviewed and updated in evidence tables, and where appropriate, changes have been made in recommendations. A new section on the use of intraoperative transesophageal echocardiography (TEE) is being added to update the guidelines published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. There are extensive revisions, especially of the sections on ischemic heart disease; congestive heart failure, cardiomyopathy, and assessment of left ventricular (LV) function; and screening and echocardiography in the critically ill. There are new tables of evidence and extensive revisions in the ischemic heart disease evidence tables.

Because of space limitations, only those sections and evidence tables with new recommendations will be printed in this summary article. Where there are minimal changes in a recommendation grouping, such as a change from Class IIa to Class I, only that change will be printed, not the entire set of recommendations. Advances for which the clinical applications are still being investigated, such as the use of myocardial contrast agents and three-dimensional echocardiography, will not be discussed.

The original recommendations of the 1997 guideline are based on a Medline search of the English literature from 1990 to May 1995. The original search yielded more than 3000 references, which the committee reviewed. For this guideline update, literature searching was conducted in Medline, EMBASE, Best Evidence, and the Cochrane Library for English-language meta-analyses and systematic reviews from 1995 through September 2001. Further searching was conducted for new clinical trials on the following topics: echocardiography in adult congenital heart disease, echocardiography for evaluation of chest pain in the emergency department, and intraoperative echocardiography. The new searches yielded more than 1000 references that were reviewed by the writing committee.

This document includes recommendations for the use of echocardiography in both adult and pediatric patients. The pediatric guidelines also include recommendations for fetal echocardiography, an increasingly important field. The guidelines include recommendations for the use of echocardiography in both specific cardiovascular disorders and the evaluation of patients with frequently observed cardiovascular symptoms and signs, common presenting complaints, or findings of dyspnea, chest discomfort, and cardiac murmur. In this way, the guidelines will provide assistance to physicians regarding the use of echocardiographic techniques in the evaluation of such common clinical problems.

The recommendations concerning the use of echocardiography follow the indication classification system (eg, Class I, II, and III) used in other American College of Cardiology/American Heart Association (ACC/AHA) guidelines:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

Evaluation of the clinical utility of a diagnostic test such as echocardiography is far more difficult than assessment of the efficacy of a therapeutic intervention because the diagnostic test can never have the same direct impact on patient survival or recovery. Nevertheless, a series of hierarchical criteria are generally accepted as a scale by which to judge worth (1–3).

Hierarchical levels of echocardiography assessment.  

• Technical capacity
  
• Diagnostic performance
  
• Impact on diagnostic and prognostic thinking
  
• Therapeutic impact
  
• Health-related outcomes
  

Because there are essentially no randomized trials assessing health outcomes for diagnostic tests, the committee has not ranked the available scientific evidence in an A, B, and C fashion (as in other ACC/AHA documents) but rather has compiled the evidence in tables. The evidence tables have been extensively revised and updated. All recommendations are thus based on either this evidence from observational studies or on the expert consensus of the committee.

The definition of echocardiography used in this document incorporates Doppler analysis, M-mode echocardiography, two-dimensional transthoracic echocardiography (TTE), and, when indicated, TEE. Intravascular ultrasound is not considered but is reviewed in the ACC/AHA Guidelines for Percutaneous Coronary Intervention (1) (available at http://www.acc.org/clinical/guidelines/percutaneous/dirIndex.htm) and the Clinical Expert Consensus Document on intravascular ultrasound (2) (available at http://www.acc.org/clinical/consensus/standards/standard12.htm). Echocardiography for evaluating the patient with cardiovascular disease for noncardiac surgery is considered in the ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery (3). The techniques of three-dimensional echocardiography are still in the developmental stages and are not considered here. New techniques that are still rapidly evolving and improvements that are purely technological in echo-Doppler instrumentation, such as color Doppler imaging and digital echocardiography, are not going to be separately discussed in the clinical recommendations addressed in this document. Tissue Doppler imaging, both pulsed and color, which detects low Doppler shift frequencies of high energy generated by the contracting myocardium and consequent wall motion, are proving very useful in evaluating systolic and diastolic myocardial function. However, these technological advances will also not be separately discussed in the clinical recommendations (4,5). Echocardiographic-contrast injections designed to assess myocardial perfusion to quantify myocardium at risk and perfusion beds also were not addressed.

These guidelines address recommendations about the frequency with which an echocardiographic study is repeated. If the frequency with which studies are repeated could be decreased without adversely affecting the quality of care, the economic savings realized would likely be significant. With a noninvasive diagnostic study and no known complications, the potential for repeating the study unnecessarily exists. It is easier to state when a repeat echocardiogram is not needed then when and how often it should be repeated, because no studies in the literature address this question. How often an echocardiogram should be done depends on the individual patient and must be left to the judgment of the physician until evidence-based data addressing this issue are available.

The ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations, as well as commentary on some of the changes. All new or revised language in recommendations appears in boldface type. Only the references supporting the new recommendations are included in this article. The reader is referred to the full-text version of the guidelines posted on the American College of Cardiology (www.acc.org), American Heart Association (www.americanheart.org), and American Society for Echocardiography (www.asecho.org) World Wide Web sites for a more detailed exposition of the rationale for these changes.

	Section II-B. native valvular stenosis

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in valvular stenosis.   Comment: New references (6,7).

Class IIb
2. Dobutamine echocardiography for the evaluation of patients with low-gradient aortic stenosis and ventricular dysfunction.

	Section II-C. native valvular regurgitation

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in native valvular regurgitation.   Comment: Literature on valvular effects of anorectic drugs and references to echocardiographic predictors of prognosis after aortic and mitral valve surgery have been added (6–10).

Class I

1. Assessment of the effects of medical therapy on the severity of regurgitation and ventricular compensation and function when it might change medical management.
   
2. Assessment of valvular morphology and regurgitation in patients with a history of anorectic drug use, or the use of any drug or agent known to be associated with valvular heart disease, who are symptomatic, have cardiac murmurs, or have a technically inadequate auscultatory examination.
   

Class III
2. Routine repetition of echocardiography in past users of anorectic drugs with normal studies or known trivial valvular abnormalities.

	Section II-F. infective endocarditis: native valves

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in infective endocarditis: native valves.   Comment: The Duke Criteria for the diagnosis of infective endocarditis have been added, as well as the value of TEE in the setting of a negative transthoracic echocardiogram when there is high clinical suspicion or when a prosthetic valve is involved (11,12).

Class I
6. If TTE is equivocal, TEE evaluation of staphylococcus bacteremia without a known source.

Class IIa
1. Evaluation of persistent nonstaphylococcus bacteremia without a known source.*

Class III
1. Evaluation of transient fever without evidence of bacteremia or new murmur.

*TEE may frequently provide incremental value in addition to information obtained by TTE. The role of TEE in first-line examination awaits further study.

	Section II-G. prosthetic valves

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in valvular heart disease and prosthetic valves.   Class I
3. Use of echocardiography (especially TEE) in guiding the performance of interventional techniques and surgery (eg, balloon valvotomy and valve repair) for valvular disease.

	Section IV-A. acute ischemic syndromes

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in the diagnosis of acute myocardial ischemic syndromes.   Comment: Movement of a recommendation from Class IIa to Class I and minor wording change.

Recommendations for echocardiography in risk assessment, prognosis, and assessment of therapy in acute myocardial ischemic syndromes.   Class I
4. Assessment of myocardial viability when required to define potential efficacy of revascularization.*

Class IIa
2. Moved to Class I (see above).

Class IIb
1. Assessment of late prognosis (greater than or equal to 2 years after acute myocardial infarction).

*Dobutamine stress echocardiography.

	Section IV-B. chronic ischemic heart disease

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in diagnosis and prognosis of chronic ischemic heart disease.   Comment: There are new sections on stress echocardiography in the detection of coronary disease in the transplanted heart and stress echocardiography in the detection of coronary disease in women. There is one new Class I recommendation and three new Class IIa recommendations. Recommendations have been renumbered for clarity.

Class I
2. Exercise echocardiography for diagnosis of myocardial ischemia in selected patients (those for whom ECG assessment is less reliable because of digoxin use, LVH or with more than 1 mm ST depression at rest on the baseline ECG, those with pre-excitation [Wolff-Parkinson-White] syndrome, complete left bundle-branch block) with an intermediate pretest likelihood of CAD.

Class IIa

1. Prognosis of myocardial ischemia in selected patients (those in whom ECG assessment is less reliable) with the following ECG abnormalities: pre-excitation (Wolff-Parkinson-White) syndrome, electronically paced ventricular rhythm, more than 1 mm of ST depression at rest, complete left bundle-branch block.*
   
2. Detection of coronary arteriopathy in patients who have undergone cardiac transplantation.
   
3. Detection of myocardial ischemia in women with a low or intermediate pretest likelihood of CAD.*
   

Class IIb
1. Moved to Class IIa.

*Exercise or pharmacological stress echocardiogram.

Dobutamine stress echocardiogram.

Recommendations for echocardiography in assessment of interventions in chronic ischemic heart disease.   One new Class IIa recommendation has been added.

Class IIa
1. Assessment of LV function in patients with previous myocardial infarction when needed to guide possible implantation of implantable cardioverter-defibrillator (ICD) in patients with known or suspected LV dysfunction.

Tables 1 through 6 are new tables that relate to CAD.

	Section V-B. regional LV function

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

Class IIb
1. Re-evaluation of patients with established cardiomyopathy when there is no change in clinical status but when the results might change management.

Class III
2. Routine re-evaluation in clinically stable patients in whom no change in management is contemplated and for whom the results would not change management.

	Section IX. pulmonary disease

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in pulmonary and pulmonary vascular disease.   Comment: One recommendation was moved from Class I to Class IIa. Class IIa recommendations have been renumbered for clarity. Evidence was added concerning the diagnosis of severe pulmonary embolism by echocardiography (122).

Class I
2. Moved to Class IIa (see below).

Class IIa
1. Pulmonary emboli and suspected clots in the right atrium or ventricle or main pulmonary artery branches.*

*TEE is indicated when TTE studies are not diagnostic.

	Section XII. arrhythmias and palpitations

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in patients with arrhythmias and palpitations.   Comment: An additional Class IIb recommendation was made concerning the use of echocardiography in the Maze procedure (123–129).

Class IIa
2. TEE or intracardiac ultrasound guidance of radiofrequency ablative procedures.

Class IIb
3. Postoperative evaluation of patients undergoing the Maze procedure to monitor atrial function.

Recommendations for echocardiography before cardioversion.   Class IIb
2. Patients with mitral valve disease or hypertrophic cardiomyopathy who have been on long-term anticoagulation at therapeutic levels before cardioversion unless there are other reasons for anticoagulation (eg, prior embolus or known thrombus on previous TEE).*

*TEE only.

Class III
2. Patients who have been on long-term anticoagulation at therapeutic levels and who do not have mitral valve disease or hypertrophic cardiomyopathy before cardioversion unless there are other reasons for anticoagulation (eg, prior embolus or known thrombus on previous TEE).*

*TEE only.

	Section XIIa. screening

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography to screen for the presence of cardiovascular disease.   Comment: A section has been added on the molecular genetics work that has identified a familial basis for many forms of cardiomyopathy, including dilated congestive cardiomyopathy, hypertrophic cardiomyopathy, and right ventricular (RV) dysplasia. A possible genetic basis for these cardiomyopathies supports echocardiographic screening of first-degree relatives (130–138).

Class I
5. First-degree relatives (parents, siblings, children) of patients with unexplained dilated cardiomyopathy in whom no etiology has been identified.

Class III
2. Routine screening echocardiogram for participation in competitive sports in patients with normal cardiovascular history, ECG, and examination.

	Section XIII. echocardiography in the critically ill

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in the critically ill.   Comment: This section has been revised extensively. A discussion has been added on the echocardiographic detection of pulmonary embolism and the usefulness of TEE versus TTE in the critically ill patient. A section on the value of echocardiography in blunt aortic trauma has also been added. The evidence tables have been extensively revised and updated (139–164).

Class III
1. Suspected myocardial contusion in the hemodynamically stable patient with a normal ECG who has no abnormal cardiac/thoracic physical findings and/or lacks a mechanism of injury that suggests cardiovascular contusion.

	Section XIV. two-dimensional echocardiography in the adult patient with congenital heart disease

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in the adult patient with congenital heart disease.   Comment: A section has been added on the accuracy of echocardiography to allow surgery to proceed without catheterization in some congenital heart lesions. Echocardiography is useful in the performance of interventional therapeutic procedures (165–177).

Class I

1. Patients with known congenital heart disease in whom it is important that pulmonary artery pressure be monitored (eg, patients with hemodynamically important, moderate, or large ventricular septal defects, atrial septal defects, single ventricle, or any of the above with an additional risk factor for pulmonary hypertension).
   
2. Periodic echocardiography in patients with repaired (or palliated) congenital heart disease with the following: change in clinical condition or clinical suspicion of residual defects, obstruction of conduits and baffles, or LV or RV function that must be monitored, or when there is a possibility of hemodynamic progression or a history of pulmonary hypertension.
   
3. Identification of site of origin and initial course of coronary arteries (TEE may be indicated in some patients).*
   

*TEE may be necessary to image both coronary origins in adults.

	Section XV-E. acquired cardiovascular disease in the neonate

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for neonatal echocardiography.   Comment: Only minor changes have been made in this section. Two new Class I recommendations and one Class III recommendation have been added (177–194). One recommendation has moved from Class IIb to Class IIa. Class I recommendations have been renumbered for clarity.

Class I

1. Re-evaluation after initiation or termination of medical therapy for pulmonary artery hypertension.
   
2. Re-evaluation during initiation or withdrawal of extracorporeal cardiopulmonary support.
   

Class IIa
3. Presence of a syndrome associated with a high incidence of congenital heart disease for which there are no abnormal cardiac findings and no urgency of management decisions.

Class IIb
1. Moved to Class IIa (see above).

Class III
2. Acrocyanosis with normal upper- and lower-extremity pulsed oximetry oxygen saturations.

	Section XV-F. congenital cardiovascular disease in the infant, child, and adolescent

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in the infant, child, and adolescent.   Comment: There are two new Class I recommendations, which have been renumbered for clarity (6,195–200).

Class I

1. Selection, placement, patency, and monitoring of endovascular devices, as well as identification of intracardiac or intravascular shunting before, during, and subsequent to interventional cardiac catheterization.
   
2. Immediate assessment after percutaneous interventional cardiac catheterization procedure.
   
3. Presence of a syndrome associated with cardiovascular disease and dominant inheritance or multiple affected family members (eg, Marfan syndrome or Ehlers-Danlos syndrome).
   

Deleted: Phenotypic findings of Marfan syndrome or Ehlers-Danlos syndrome.

Presence of a syndrome associated with high incidence of congenital heart disease when there are no abnormal cardiac findings.

"Atypical," "nonvasodepressor" syncope without other causes.

	Section XV-G. arrhythmias/conduction disturbances

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in pediatric patients with arrhythmias/conduction disturbances.   Comment: Echocardiography is discretionary after radiofrequency catheter ablation. Persistent ventricular dilatation after successful ablation or effective medical control of the heart rate may indicate an arrhythmogenic primary cardiomyopathy (201–203).

Class IIa
2. Evidence of pre-excitation on ECG with symptoms.

Class IIb
3. Examination immediately after radiofrequency ablation.

	Section XV-H. acquired cardiovascular disease

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in pediatric acquired cardiovascular disease.   Comment: The leading cause of death after the first posttransplant year is transplant-related CAD. There is evidence that stress echocardiography identifies subclinical ischemia (204–213).

Class I

1. Baseline and re-evaluation examinations of patients receiving cardiotoxic chemotherapeutic agents.
   
2. Patients with severe renal disease and/or systemic hypertension.
   

Class III
1. Routine screening echocardiogram for participation in competitive sports in patients with normal cardiovascular examination.

	Section XV-I. pediatric acquired cardiopulmonary disease

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for echocardiography in pediatric acquired cardiopulmonary disease.   Comment: Echocardiography provides documentation of pulmonary artery hypertension and estimation of severity by the presence of RV dilation and/or hypertrophy, the presence of tricuspid or pulmonic valvular regurgitation, and Doppler estimation of RV systolic pressure (214,215).

Class I

1. Re-evaluation after surgical intervention or initiation of oral and/or parenteral vasodilator therapy for pulmonary artery hypertension.
   
2. Re-evaluation during withdrawal of extracorporeal cardiopulmonary support.
   

	Section XV-K. transesophageal echocardiography

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for TEE in pediatric patients.   Comment: TEE has become particularly helpful in guiding placement of catheter-deployed devices used in closing atrial septal defects. It is essential in ensuring proper positioning of the device in the defect and assessing for residual shunts and abnormal device occlusion of venous inflow into the atria or encroachment on the atrioventricular valves. Likewise, placement of catheters for radiofrequency ablation of arrhythmogenic pathways can be facilitated by TEE when there are intracardiac abnormalities (216–222).

Class I

1. Monitoring and guidance during cardiothoracic surgicalprocedures.
   
2. Patients with right atrial to pulmonary artery Fontan connection, for identification of atrial thrombus.
   

Class IIa
1. Patients with lateral tunnel Fontan palliation.

	Section XVI. intraoperative echocardiography

Top I. General considerations and... Section II-B. native valvular... Section II-C. native valvular... Section II-F. infective... Section II-G. prosthetic valves Section IV-A. acute ischemic... Section IV-B. chronic ischemic... Section V-B. regional LV... Section IX. pulmonary disease Section XII. arrhythmias and... Section XIIa. screening Section XIII. echocardiography... Section XIV. two-dimensional... Section XV-E. acquired... Section XV-F. congenital... Section XV-G.... Section XV-H. acquired... Section XV-I. pediatric acquired... Section XV-K. transesophageal... Section XVI. intraoperative... References

 
Recommendations for intraoperative echocardiography.   Comment: This section is new. In 1996, a task force of the American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists (ASA/SCA) published practice guidelines for perioperative TEE. The guidelines were evidence based and focused on the effectiveness of perioperative TEE in improving clinical outcomes. A literature search conducted at that time retrieved 1844 articles, of which 588 were considered relevant to the perioperative setting. A more recent literature search identified an additional 118 articles related to the intraoperative use of echocardiography. The current text makes reference only to the latter. However, the indications for intraoperative echocardiography that are provided in these guidelines are based on both the initial ASA/SCA guidelines and the newer information (223–260).

For a detailed discussion of this topic, please see the full-text version of the guidelines posted on the ACC, AHA, and American Society of Echocardiography (ASE) World Wide Web sites.

Class I

1. Evaluation of acute, persistent, and life-threatening hemodynamic disturbances in which ventricular function and its determinants are uncertain and have not responded to treatment.
   
2. Surgical repair of valvular lesions, hypertrophic obstructive cardiomyopathy, and aortic dissection with possible aortic valve involvement.
   
3. Evaluation of complex valve replacements requiring homografts or coronary reimplantation, such as the Ross procedure.
   
4. Surgical repair of most congenital heart lesions that require cardiopulmonary bypass.
   
5. Surgical intervention for endocarditis when preoperative testing was inadequate or extension to perivalvular tissue is suspected.