Transthoracic Echocardiography

1 Major Symptom or Complaint presented as primary indication

1.1 Acute coronary syndrome

1.2 Atrial fibrillation/flutter

1.3 Chest pain

1.4 Dizziness

1.5 Fatigue

1.6 Frequent ventricular premature contractions

1.7 Hemodynamic instability

1.8 Hypertension

1.9 Hypotension

1.10 Hypoxemia

1.11 Irregular heartbeat

1.12 Myocardial infarction (heart attack)

1.13 Palpitations

1.14 Presyncope (lightheadedness)

1.15 Respiratory failure

1.16 Shortness of breath (dyspnea)

1.17 Stroke

1.18 Supraventricular tachycardia

1.19 Swelling of the ankles and feet (edema)

1.20 Syncope (fainting)

1.21 Transient ischemic attack (TIA)

1.22 Ventricular fibrillation

1.23 Ventricular tachycardia

1.24 Worsening heart failure symptoms

• 1.24.1 Chest pain
• 1.24.2 Lower extremity edema
• 1.24.3 Pleural effusion
• 1.24.4 Shortness of breath (dyspnea)

2 Working Diagnosis or Rule Out presented as primary indication

2.1 Acute aortic pathology, suspected

2.2 Cardiac mass or tumor, suspected

2.3 Cardiac source of embolus, suspected

2.4 Cardiac thrombus, suspected

2.5 Cardiomyopathy, suspected

2.6 Complication of myocardial ischemia or infarction, suspected

2.7 Determine candidacy for implantable device

2.8 Infective endocarditis, suspected

• 2.8.1 Intracardiac device
• 2.8.2 New murmur
• 2.8.3 Positive blood cultures
• 2.8.4 Prosthetic heart valve

2.9 Pulmonary hypertension, suspected

2.10 Reasonable suspicion for valvular heart disease

• 2.10.1 Chest pain
• 2.10.2 Dizziness
• 2.10.3 Fatigue
• 2.10.4 Irregular heartbeat
• 2.10.5 Palpitations
• 2.10.6 Presyncope (lightheadedness)
• 2.10.7 Shortness of breath (dyspnea)
• 2.10.8 Swelling of the ankles and feet (edema)
• 2.10.9 Syncope (fainting)

3 Abnormal Physical Exam Finding presented as primary indication

3.1 Chronic mitral regurgitation (MR)

3.2 Hypertension

3.3 Hypotension

3.4 Murmur or abnormal heart sounds

3.5 Swelling of the ankles and feet (edema)

4 Abnormal Lab or Imaging presented as primary indication

4.1 Ascending aortic dilatation or aneurysm

4.2 Atrial fibrillation/flutter

4.3 Chronic mitral regurgitation (MR)

4.4 Left bundle branch block (LBBB)

4.5 Left ventricular systolic dysfunction

4.6 Low ejection fraction (<50%)

4.7 Pericardial effusion

4.8 Positive blood cultures and suspect infective endocarditis

4.9 Re-evaluation of prior abnormal transthoracic echocardiogram or transesophageal echocardiogram finding

4.10 Right bundle branch block (RBBB)

4.11 Supraventricular tachycardia

4.12 Ventricular fibrillation

4.13 Ventricular premature contractions

4.14 Ventricular tachycardia

5 Significant Prior Medical History presented as primary indication

5.1 Acute aortic pathology

5.2 Amyloidosis

5.3 Ascending aortic dilatation or aneurysm

5.4 Bicuspid aortic valve

5.4.1 Aortic diameter >4.0 cm with rapid change or family history

• 5.4.1.1 Repeat imaging at interval <1 year

5.4.2 Aortic diameter >4.5 cm

• 5.4.2.1 Repeat imaging at interval <1 year

5.4.3 Initial evaluation

5.5 Cardiac or pericardial mass or tumor

5.6 Cardiac source of embolus

5.7 Cardiac surgery or procedure

5.7.1 Assessment following PFO or ASD closure

• 5.7.1.1 6-month routine follow-up device closure
• 5.7.1.2 Clinical concern for infection, malposition, embolization, or persistent shunt

5.7.2 Assessment following left atrial appendage occlusion

• 5.7.2.1 Long-term follow-up
• 5.7.2.2 Prior to discharge
• 5.7.2.3 Surveillance at 45 days per FDA guidance

5.7.3 Evaluation after heart surgery

5.7.4 Evaluation of cardiac structure and function during cardiac intervention

• 5.7.4.1 Preprocedural evaluation for ASD closure
• 5.7.4.2 Preprocedural evaluation for PFO closure
• 5.7.4.3 Preprocedural evaluation for LAA occlusion
• 5.7.4.4 Screen for intraprocedural complications for LAA occlusion

5.7.5 Implantable device

• 5.7.5.1 Follow-up after placement
• 5.7.5.2 Suspected complication
• 5.7.5.3 Suspected infection
• 5.7.5.4 Worsening heart failure symptoms

5.7.6 Percutaneous mitral valve repair

5.7.6.1 Post-procedural evaluation

• 5.7.6.1.1 Annually to 5 years for assessment of mitral regurgitation and left ventricular function
• 5.7.6.1.2 At 1 month
• 5.7.6.1.3 At 1 year
• 5.7.6.1.4 At 6 months
• 5.7.6.1.5 Prior to discharge
• 5.7.6.1.6 Suspicion of post-procedural valve dysfunction

5.7.6.2 Prior to percutaneous mitral valve repair

5.7.7 Postoperative imaging after surgical valve replacement or repair

5.7.7.1 Mitral valve repair with no symptoms or stable symptoms

• 5.7.7.1.1 Initial postoperative assessment (6 weeks to 3 months postoperative)
• 5.7.7.1.2 Re-evaluation ≥3 years later absent suspected dysfunction

5.7.7.2 Mitral valve repair with suspected dysfunction

5.7.7.3 Surgical valve replacement with no symptoms or stable symptoms

• 5.7.7.3.1 Initial postoperative evaluation (6 weeks to 3 months postoperative)
• 5.7.7.3.2 Re-evaluation after first 10 years for bioprosthesis
• 5.7.7.3.3 Re-evaluation prior to pregnancy absent echocardiogram within last year
• 5.7.7.3.4 Re-evaluation ≥3 years for mechanical or tissue valves

5.7.7.4 Surgical valve replacement with suspicion of valve dysfunction

• 5.7.7.4.1 Evaluation of infective endocarditis
• 5.7.7.4.2 Mechanical or tissue valve with concern for valve dysfunction
• 5.7.7.4.3 Re-evaluation of known prosthetic valve dysfunction when it would help guide therapy

5.7.8 Transcatheter aortic valve replacement

• 5.7.8.1 Intra-procedural assessment
• 5.7.8.2 Pre-TAVR assessment
• 5.7.8.3 Suspicion of post-procedural valve dysfunction

5.8 Cardiac thrombus

5.9 Cardiomyopathy

5.10 Congenital heart disease

5.11 Diabetes

5.12 Exposure to medications/radiation that could result in cardiotoxicity

5.13 First-degree relative with inherited cardiomyopathy

5.14 First-degree relative with aortic aneurysm or dissection

5.15 First-degree relative with bicuspid aortic valve

5.16 Heart failure

5.17 Hypertension

5.18 Hypotension

5.19 Infective endocarditis

5.20 Left ventricular systolic dysfunction

5.21 Marfan syndrome

5.22 Myocardial infarction (heart attack)

5.23 Noonan syndrome

5.24 Pericardial constriction

5.25 Pericardial effusion

5.26 Potential heart donor

5.27 Preparticipation assessment of asymptomatic athlete with ≥1 of the following

• 5.27.1 Abnormal electrocardiogram (ECG)
• 5.27.2 Abnormal physical examination
• 5.27.3 Family history of inheritable heart disease

5.28 Psoriasis

5.29 Pulmonary hypertension

5.30 Rheumatic heart disease

5.31 Rheumatoid arthritis

5.32 Sarcoidosis

5.33 Stroke

5.34 Structural heart disease

• 5.34.1 Change in cardiac examination
• 5.34.2 Change in clinical status
• 5.34.3 Re-evaluation to guide therapy

5.35 Systemic lupus erythematosus (SLE)

5.36 Transient ischemic attack (TIA)

5.37 Turner syndrome

5.38 Valvular heart disease

5.38.1 After control of systemic hypertension in patients with low-flow, low-gradient severe aortic stenosis

5.38.2 Asymptomatic severe (stage C1) aortic stenosis

• 5.38.2.1 Every 1 year

5.38.3 Asymptomatic severe (stage C1) mitral regurgitation

• 5.38.3.1 Every 6–12 months

5.38.4 Change in clinical status or cardiac examination

5.38.5 Moderate (stage B) VHD

• 5.38.5.1 Every 1–2 years

5.38.6 Re-evaluation to guide therapy

5.38.7 Stage A (at risk) or stage B (mild) valve regurgitation

• 5.38.7.1 Every 3–5 years

5.39 Vasculitis

References

• David S. Bach, American College of Cardiology (2017). “2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease”
• John U. Doherty et al., Journal of the American College of Cardiology (September 2017, 70(13):1647–1672). “ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease”
• American College of Cardiology (January 2019). “New AUC: Multimodality Imaging in Assessing Cardiac Structure and Function in Structural Heart Disease”
• John U. Doherty et al., Journal of the American College of Cardiology (February 2019, 73(4):488–516). “ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease”
• Debabrata Mukherjee, American College of Cardiology (January 2019). “2019 Appropriate Use Criteria for Multimodality Imaging in Nonvalvular Heart Disease”
• Singh A and Ward RP, Current Cardiology Reports (September 2016, 18(9):93). “Appropriate Use Criteria for Echocardiography: Evolving Applications in Value-Based Healthcare”