general

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DERMATITIS</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Stuttering"><U>Stuttering</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="enuresis"><U>enuresis</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="Conduct Disorder in Children and Adolesc"><U>Conduct Disorder in Children and Adolescents </U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="Specific Growth Curve Deviations "><U>Specific Growth Curve Deviations </U></A>   |   <A HREF="id23.htm" TARGET="_top" TITLE="Common Medical and Surgical Problems"><U>Common Medical and Surgical Problems</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="Chronic Abdominal Pain in Childhood: Dia"><U>Chronic Abdominal Pain in Childhood: Diagnosis and Management </U></A>   |   <A HREF="id25.htm" TARGET="_top" TITLE="child devlpt"><U>child devlpt</U></A>   |   <A HREF="id26.htm" TARGET="_top" TITLE="ACETAMINOPHEN OVERDOSE"><U>ACETAMINOPHEN OVERDOSE</U></A>   |   <A HREF="id27.htm" TARGET="_top" TITLE="SHAKEN BABY SYNDROME"><U>SHAKEN BABY SYNDROME</U></A>   |   <A HREF="id28.htm" TARGET="_top" TITLE="NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)"><U>NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</U></A>   |   <A HREF="id29.htm" TARGET="_top" TITLE="Hyaline Membrane Disease (Respiratory Di"><U>Hyaline Membrane Disease (Respiratory Distress Syndrome) (HMD) (RDS</U></A>   |   <A HREF="id30.htm" TARGET="_top" TITLE="infectious disease"><U>infectious disease</U></A>   |   <A HREF="id32.htm" TARGET="_top" TITLE="HEMORRHAGIC DISEASE IN A NEW BORN"><U>HEMORRHAGIC DISEASE IN A NEW BORN</U></A>   |   <A HREF="id33.htm" TARGET="_top" TITLE="OPTIC NERVE GLIOMA"><U>OPTIC NERVE GLIOMA</U></A>   |   <A HREF="id36.htm" TARGET="_top" TITLE="New Born Assessment "><U>New Born Assessment </U></A>   |   <A HREF="id38.htm" TARGET="_top" TITLE="laryngomalacia"><U>laryngomalacia</U></A>   |   <A HREF="id39.htm" TARGET="_top" TITLE="CRANIOSYNOSTOSIS "><U>CRANIOSYNOSTOSIS </U></A>   |   <A HREF="id40.htm" TARGET="_top" 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Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#CCCCFF" TEXT="#080000" background="04411c00egdysm.gif"> <div> <A HREF="id31.htm" TARGET="_top" TITLE="PEDIATRIC PEARLS FOR THE USMLE"><U><B>PEDIATRIC PEARLS FOR THE USMLE</B></U></A></div> <div> <A HREF="id48.htm" TARGET="_top" TITLE="pearls pediatry 2"><U><B>pearls pediatry 2</B></U></A></div> <div> <B>general</B></div> <div> <A HREF="id34.htm" TARGET="_top" TITLE="appendiceal colic"><U><B>appendiceal colic</B></U></A></div> <div> <A HREF="id35.htm" TARGET="_top" TITLE="ATOPIC DERMATITIS"><U><B>ATOPIC DERMATITIS</B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="Stuttering"><U><B>Stuttering</B></U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="enuresis"><U><B>enuresis</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="Conduct Disorder in Children and Adolesc"><U><B>Conduct Disorder in Children and Adolescents </B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="Specific Growth Curve Deviations "><U><B>Specific Growth Curve Deviations </B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="Common Medical and Surgical Problems"><U><B>Common Medical and Surgical Problems</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="Chronic Abdominal Pain in Childhood: Dia"><U><B>Chronic Abdominal Pain in Childhood: Diagnosis and Management </B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="child devlpt"><U><B>child devlpt</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="ACETAMINOPHEN OVERDOSE"><U><B>ACETAMINOPHEN OVERDOSE</B></U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="SHAKEN BABY SYNDROME"><U><B>SHAKEN BABY SYNDROME</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)"><U><B>NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Hyaline Membrane Disease (Respiratory Di"><U><B>Hyaline Membrane Disease (Respiratory Distress Syndrome) (HMD) (RDS</B></U></A></div> <div> <A HREF="id30.htm" TARGET="_top" TITLE="infectious disease"><U><B>infectious disease</B></U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="HEMORRHAGIC DISEASE IN A NEW BORN"><U><B>HEMORRHAGIC DISEASE IN A NEW BORN</B></U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="OPTIC NERVE GLIOMA"><U><B>OPTIC NERVE GLIOMA</B></U></A></div> <div> <A HREF="id36.htm" TARGET="_top" TITLE="New Born Assessment "><U><B>New Born Assessment </B></U></A></div> <div> <A HREF="id38.htm" TARGET="_top" TITLE="laryngomalacia"><U><B>laryngomalacia</B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="CRANIOSYNOSTOSIS "><U><B>CRANIOSYNOSTOSIS </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="DANDYWALKER MALFORMATION "><U><B>DANDY-WALKER MALFORMATION </B></U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="DEJERINESOTTAS DISEASE "><U><B>DEJERINE-SOTTAS DISEASE </B></U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="DOWN SYNDROME "><U><B>DOWN SYNDROME </B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Respiratory Syncytial Virus (RSV)"><U><B>Respiratory Syncytial Virus (RSV)</B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="FABRY DISEASE "><U><B>FABRY DISEASE </B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="PRADERWILLI SYNDROME "><U><B>PRADER-WILLI SYNDROME </B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="new born fun"><U><B>new born fun</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="RETT SYNDROME "><U><B>RETT SYNDROME </B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Alexander Disease"><U><B>Alexander Disease</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="leukemia"><U><B>leukemia</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> general</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">D blood typing and antibody testing is recommended for all pregnant women at their first prenatal visit, including visits for elective abortion </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> For purposes of blood typing and prophylaxis, Du- and D-negative blood types should be considered equivalent.22</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Unless the father is known to be D-negative, a repeat D antibody test is recommended for all unsensitized D-negative women at<B><U> 24-28 weeks' gestation</U></B>, followed by the administration of a full (300 micro-g) dose of D immunoglobulin if they are antibody-negative </div> <div> . </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If a D- (or Du-) positive infant is delivered, the dose should be repeated postpartum, preferably within 72 hours after delivery  Unless the father is known to be D-negative, a full dose of D immunoglobulin is recommended for all unsensitized D-negative women after elective abortion (50 micro-g before 13 weeks) and amniocentesis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is currently insufficient evidence to recommend for or against the routine administration of D immunoglobulin after other obstetric procedures or complications such as chorionic villus sampling, ectopic pregnancy termination, cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, antepartum fetal death, and stillbirth </div> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B>Indications for Echocardiography in the Evaluation of Heart Murmurs</B> <B>Class</B> </div> <bR> <div> 1. A murmur in a patient with cardiorespiratory symptoms. I 2. A murmur in an asymptomatic patient if the clinical features indicate at least a moderate probability that the murmur is reflective of structural heart disease. I 3. A murmur in an asymptomatic patient in whom there is a low probability of heart disease but in whom the diagnosis of heart disease cannot be reasonably excluded by the standard cardiovascular clinical evaluation. IIa 4. In an adult, an asymptomatic heart murmur that has been identified by an experienced observer as functional or innocent. III </div> <bR> <div> <B>Indications for Echocardiography in Valvular Stenosis</B> <B>Class</B> </div> <bR> <div> 1. Diagnosis; assessment of hemodynamic severity. I 2. Assessment of left ventricular (LV) and right ventricular (RV) size, function, and/or hemodynamics. I 3. Reevaluation of patients with known valvular stenosis with changing symptoms or signs. I 4. Assessment of changes in hemodynamic severity and ventricular compensation in patients with known valvular stenosis during pregnancy. I 5. Reevaluation of asymptomatic patients with severe stenosis. I 6. Assessment of the hemodynamic significance of mild to moderate valvular stenosis by Doppler echocardiography. IIa 7. Reevaluation of patients with mild to moderate aortic stenosis with LV dysfunction or hypertrophy even without clinical symptoms. IIa 8. Reevaluation of patients with mild to moderate aortic valvular stenosis with stable signs and symptoms. IIb 9. Routine reevaluation of asymptomatic adult patients with mild aortic stenosis having stable physical signs and normal LV size and function. III 10. Routine reevaluation of asymptomatic patients with mild to moderate mitral stenosis and stable physical signs. III (See also "Indications for Echocardiography in Interventions for Valvular Heart Disease and Prosthetic Valves.") </div> <bR> <div> <B>Indications for Echocardiography in Native Valvular Regurgitation</B> <B>Class</B> </div> <bR> <div> 1. Diagnosis; assessment of hemodynamic severity. I 2. Initial assessment and reevaluation (when indicated) of LV and RV size, function, and/or hemodynamics. I 3. Reevaluation of patients with mild to moderate valvular regurgitation with changing symptoms. I 4. Reevaluation of asymptomatic patients with severe regurgitation. I 5. Assessment of changes in hemodynamic severity and ventricular compensation in patients with known valvular regurgitation during pregnancy. I 6. Reevaluation of patients with mild to moderate regurgitation with ventricular dilation without clinical symptoms. I 7. Assessment of the effects of medical therapy on the severity of regurgitation and ventricular compensation and function. I 8. Reevaluation of patients with mild to moderate mitral regurgitation without chamber dilation and without clinical symptoms. IIb 9. Reevaluation of patients with moderate aortic regurgitation without chamber dilation and without clinical symptoms. IIb 10. Routine reevaluation in asymptomatic patients with mild valvular regurgitation having stable physical signs and normal LV size and function. III (See also "Indications for Echocardiography in Interventions for Valvular Heart Disease and Prosthetic Valves.") </div> <bR> <div> <B>Indications for Echocardiography in Mitral Valve Prolapse</B> <B>Class</B> </div> <bR> <div> 1. Diagnosis; assessment of hemodynamic severity, leaflet morphology, and/or ventricular compensation in patients with physical signs of MVP. I 2. To exclude MVP in patients who have been diagnosed but without clinical evidence to support the diagnosis. IIa 3. To exclude MVP in patients with first-degree relatives with known myxomatous valve disease. IIa 4. Risk stratification in patients with physical signs of MVP or known MVP. IIa 5. Exclusion of MVP in patients with ill-defined symptoms in the absence of a constellation of clinical symptoms or physical findings suggestive of MVP or a positive family history. III 6. Routine repetition of echocardiography in patients with MVP with no or mild regurgitation and no changes in clinical signs or symptoms. III </div> <bR> <div> <B>Indications for Echocardiography in Infective Endocarditis: Native Valves</B> <B>Class</B> </div> <bR> <div> 1. Detection and characterization of valvular lesions, their hemodynamic severity, and/or ventricular compensation.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 2. Detection of vegetations and characterizations of lesions in patients with congenital heart disease suspected of having infective endocarditis. I 3. Detection of associated abnormalities (e.g., abscesses, shunts, etc).<FONT SIZE="1" COLOR="#000000" FACE="arial" >* </FONT>I 4. Reevaluation studies in complex endocarditis (e.g., virulent organism, severe hemodynamic lesion, aortic valve involvement, persistent fever or bacteremia, clinical change, or symptomatic deterioration). I 5. Evaluation of patients with high clinical suspicion of culture-negative endocarditis.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 6. Evaluation of bacteremia without a known source.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 7. Risk stratification in established endocarditis.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 8. Routine reevaluation in uncomplicated endocarditis during antibiotic therapy. IIb 9. Evaluation of fever and nonpathological murmur without evidence of bacteremia. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE may provide incremental value in addition to information obtained by TTE. The role of TEE in first-line examination awaits further study. </div> <bR> <div> <B>Indications for Echocardiography in Interventions for Valvular Heart Disease and Prosthetic Valves</B> <B>Class</B> </div> <bR> <div> 1. Assessment of the timing of valvular intervention based on ventricular compensation, function, and/or severity of primary and secondary lesions. I 2. Selection of alternative therapies for mitral valve disease (such as balloon valvuloplasty, operative valve repair, valve replacement).<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Use of echocardiography (especially TEE) in performing interventional techniques (e.g., balloon valvotomy) for valvular disease. I 4. Postintervention baseline studies for valve function (early) and ventricular remodeling (late). I 5. Reevaluation of patients with valve replacement with changing clinical signs and symptoms; suspected prosthetic dysfunction (stenosis, regurgitation) or thrombosis.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 6. Routine reevaluation study after baseline studies of patients with valve replacements with mild to moderate ventricular dysfunction without changing clinical signs or symptoms. IIa 7. Routine reevaluation at the time of increased failure rate of a bioprosthesis without clinical evidence of prosthetic dysfunction. IIb 8. Routine reevaluation of patients with valve replacements without suspicion of valvular dysfunction and unchanged clinical signs and symptoms. III 9. Patients whose clinical status precludes therapeutic interventions. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE may provide incremental value in addition to information obtained by TTE. </div> <bR> <div> <B>Indications for Echocardiography in Infective Endocarditis: Prosthetic Valves</B> <B>Class</B> </div> <bR> <div> 1. Detection and characterization of valvular lesions, their hemodynamic severity, and/or ventricular compensation.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 2. Detection of associated abnormalities (e.g., abscesses, shunts, etc).<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Reevaluation in complex endocarditis (e.g., virulent organism, severe hemodynamic lesion, aortic valve involvement, persistent fever or bacteremia, clinical change, or symptomatic deterioration).<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 4. Evaluation of suspected endocarditis and negative cultures.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 5. Evaluation of bacteremia without known source.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 6. Evaluation of persistent fever without evidence of bacteremia or new murmur.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 7. Routine reevaluation in uncomplicated endocarditis during antibiotic therapy.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIb 8. Evaluation of transient fever without evidence of bacteremia or new murmur. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE may provide incremental value in addition to that obtained by TTE. </div> <bR> <div> <B>Indications for Echocardiography in Patients With Chest Pain Class</B> </div> <bR> <div> 1. Diagnosis of underlying cardiac disease in patients with chest pain and clinical evidence of valvular, pericardial, or primary myocardial disease (see sections II, IV through VI, VIII, and IX). I 2. Evaluation of chest pain in patients with suspected acute myocardial ischemia, when baseline ECG is nondiagnostic and when study can be obtained during pain or soon after its abatement (see section IV). I 3. Evaluation of chest pain in patients with suspected aortic dissection (see section VIII). I 4. Chest pain in patients with severe hemodynamic instability (see section XIII). I 5. Evaluation of chest pain for which a noncardiac etiology is apparent. III 6. Diagnosis of chest pain in a patient with electrocardiographic changes diagnostic of myocardial ischemia/infarction. III </div> <bR> <div> <B>Indications for Echocardiography in the Diagnosis of Acute Myocardial Ischemic Syndromes</B> <B>Class</B> </div> <bR> <div> 1. Diagnosis of suspected acute ischemia or infarction not evident by standard means. I 2. Measurement of baseline LV function. I 3. Patients with inferior myocardial infarction and bedside evidence suggesting possible RV infarction I 4. Assessment of mechanical complications and mural thrombus.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 5. Identification of location/severity of disease in patients with ongoing ischemia. IIa 6. Diagnosis of acute myocardial infarction already evident by standard means. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE is indicated when TTE studies are not diagnostic. </div> <bR> <div> <B>Indications for Echocardiography in Risk Assessment, Prognosis, and Assessment of Therapy in Acute Myocardial Ischemic Syndromes</B> <B>Class</B> </div> <bR> <div> 1. Assessment of infarct size and/or extent of jeopardized myocardium. I 2. In-hospital assessment of ventricular function when the results are used to guide therapy. I 3. In-hospital or early postdischarge assessment of the presence/extent of inducible ischemia whenever baseline abnormalities are expected to compromise electrocardiographic interpretation.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 4. In-hospital or early postdischarge assessment of the presence/extent of inducible ischemia in the absence of baseline abnormalities expected to compromise ECG interpretation.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 5. Assessment of myocardial viability when required to define potential efficacy of revascularization.<FONT SIZE="1" COLOR="#000000" FACE="arial" >**</FONT> IIa 6. Reevaluation of ventricular function during recovery when results are used to guide therapy. IIa 7. Assessment of ventricular function after revascularization. IIa 8. Assessment of long-term prognosis (<U>></U> 2 years after acute myocardial infarction). IIb 9. Routine reevaluation in the absence of any change in clinical status. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>Exercise or pharmacological stress echocardiogram.</div> <div> **<FONT SIZE="3" COLOR="#000000" FACE="arial" >Dobutamine stress echocardiogram. </FONT></div> <bR> <div> <B>Indications for Echocardiography in Diagnosis and Prognosis of Chronic Ischemic Heart Disease</B> <B>Class</B> </div> <bR> <div> 1. Diagnosis of myocardial ischemia in symptomatic individuals.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 2. Assessment of global ventricular function at rest. I 3. Assessment of myocardial viability (hibernating myocardium) for planning revascularization.<FONT SIZE="1" COLOR="#000000" FACE="arial" >**</FONT> I 4. Assessment of functional significance of coronary lesions (if not already known) in planning percutaneous transluminal coronary angioplasty.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 5. Diagnosis of myocardial ischemia in selected patients with an intermediate or high pretest likelihood of coronary artery disease.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIb 6. Assessment of an asymptomatic patient with positive results from a screening treadmill test. IIb 7. Assessment of global ventricular function with exercise.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIb 8. Screening of asymptomatic persons with a low likelihood of coronary artery disease. III 9. Routine periodic reassessment of stable patients for whom no change in therapy is contemplated. III 10. Routine substitution for treadmill exercise testing in patients for whom ECG analysis is expected to suffice. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>Exercise or pharmacological stress echocardiogram.</div> <div> **<FONT SIZE="3" COLOR="#000000" FACE="arial" >Dobutamine stress echocardiogram. </FONT></div> <bR> <div> <B>Indications for Echocardiography in Assessment of Interventions in Chronic Ischemic Heart Disease</B> <B>Class </B></div> <bR> <div> 1. Assessment of LV function when needed to guide institution and modification of drug therapy in patients with known or suspected LV dysfunction. I 2. Assessment for restenosis after revascularization in patients with atypical recurrent symptoms.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Assessment for restenosis after revascularization in patients with typical recurrent symptoms.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 4. Routine assessment of asymptomatic patients after revascularization. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>Exercise or pharmacological stress echocardiography. </div> <bR> <div> <B>Indications for Echocardiography in Patients With Dyspnea, Edema, or Cardiomyopathy</B> <B>Class</B> </div> <bR> <div> 1. Assessment of LV size and function in patients with suspected cardiomyopathy or clinical diagnosis of heart failure.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 2. Edema with clinical signs of elevated central venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot be estimated with confidence and clinical suspicion of heart disease is high.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Dyspnea with clinical signs of heart disease. I 4. Patients with unexplained hypotension, especially in the intensive care unit.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 5. Patients exposed to cardiotoxic agents, to determine the advisability of additional or increased dosages. I 6. Reevaluation of LV function in patients with established cardiomyopathy when there has been a documented change in clinical status or to guide medical therapy. I 7. Reevaluation of patients with established cardiomyopathy when there is no change in clinical status. IIb 8. Reevaluation of patients with edema when a potential cardiac cause has already been demonstrated. IIb 9. Evaluation of LV ejection fraction in patients with recent (contrast or radionuclide) angiographic determination of ejection fraction. III 10. Routine reevaluation in clinically stable patients in whom no change in management is contemplated. III 11. In patients with edema, normal venous pressure, and no evidence of heart disease. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE is indicated when TTE studies are not diagnostic. </div> <bR> <div> <B>Indications for Echocardiography in Pericardial Disease</B> <B>Class</B> </div> <bR> <div> 1. Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process. I 2. Patients with suspected bleeding in the pericardial space, e.g., trauma, perforation, etc. I 3. Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal directed to answer a specific clinical question. I 4. Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea. I 5. Follow-up studies to detect early signs of tamponade in the presence of large or rapidly accumulating effusions. A goal-directed study may be appropriate. IIa 6. Echocardiographic guidance and monitoring of pericardiocentesis. IIa 7. Postsurgical pericardial disease, including postpericardiotomy syndrome, with potential for hemodynamic impairment. IIb 8. In the presence of a strong clinical suspicion and nondiagnostic TTE, TEE assessment of pericardial thickness to support a diagnosis of constrictive pericarditis. IIb 9. Routine follow-up of small pericardial effusion in clinically stable patients. III 10. Follow-up studies in patients with cancer or other terminal illness for whom management would not be influenced by echocardiographic findings. III 11. Assessment of pericardial thickness in patients without clinical evidence of constrictive pericarditis. III 12. Pericardial friction rub in early uncomplicated myocardial infarction or early postoperative period after cardiac surgery. III </div> <bR> <div> <B>Indications for Echocardiography in Patients With Cardiac Masses and Tumors</B> <B>Class</B> </div> <bR> <div> 1. Evaluation of patients with clinical syndromes and events suggesting an underlying cardiac mass. I 2. Evaluation of patients with underlying cardiac disease known to predispose to mass formation for whom a therapeutic decision regarding surgery or anticoagulation will depend on the results of echocardiography. I 3. Follow-up or surveillance studies after surgical removal of masses known to have a high likelihood of recurrence (ie, myxoma). I 4. Patients with known primary malignancies when echocardiographic surveillance for cardiac involvement is part of the disease staging process. I 5. Screening persons with disease states likely to result in mass formation but for whom no clinical evidence for the mass exists. IIb 6. Patients for whom the results of echocardiography will have no impact on diagnosis or clinical decision making. III </div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="629" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 20 ><NOBR><div> <B>Indications for Echocardiography in Suspected Thoracic Aortic Disease </B></div> </NOBR></tD> <tD VALIGN=TOP COLSPAN=2 WIDTH="67"><div> <B>Class</B> </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 HEIGHT= 19 WIDTH="619"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="619" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="127"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="127" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="423"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="423" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> <B>TTE</B> </div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <B>TEE</B> </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="127"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="127" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="423"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="423" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP COLSPAN=2 WIDTH="67"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="67" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="127"><div> 1. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Aortic dissection. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIa </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="127"><div> 2. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Aortic aneurysm. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="127"><div> 3. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Aortic rupture. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIb </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="127"><div> 4. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Aortic root dilatation in Marfan or other connective tissue syndromes. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIb </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="127"><div> 5. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Degenerative or traumatic aortic disease with clinical atheroembolism. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIb </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="127"><div> 6. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Follow-up of aortic dissection, especially after surgical repair without suspicion of complication or progression. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIa </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="127"><div> 7. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> Follow-up of aortic dissection especially after surgical repair when complication or progression is suspected. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIa </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="127"><div> 8. </div> </tD> <tD VALIGN=TOP WIDTH="423"><div> First-degree relative of a patient with Marfan syndrome or other connective tissue disorder. </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> I </div> </tD> <tD VALIGN=TOP WIDTH="33"><div> IIb </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 HEIGHT= 20 WIDTH="619"><div> *<FONT SIZE="3" COLOR="#000000" FACE="arial" >Especially for aortic root aneurysm. </FONT></div> </tD> </tR> </TABLE></div> <bR> <div> <B>Indications for Echocardiography in Pulmonary Disease Class</B> </div> <bR> <div> 1. Suspected pulmonary hypertension. I 2. Pulmonary emboli and suspected clots in the right atrium or ventricle or main pulmonary artery branches.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. For distinguishing cardiac versus noncardiac etiology of dyspnea in patients in whom all clinical and laboratory clues are ambiguous.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 4. Follow-up of pulmonary artery pressures in patients with pulmonary hypertension to evaluate response to treatment. I 5. Lung disease with clinical suspicion of cardiac involvement (suspected cor pulmonale). I 6. Measurement of exercise pulmonary artery pressure. IIa 7. Patients being considered for lung transplantation or other surgical procedure for advanced lung disease.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 8. Lung disease without any clinical suspicion of cardiac involvement. III 9. Reevaluation studies of RV function in patients with chronic obstructive lung disease without a change in clinical status. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE is indicated when TTE studies are not diagnostic. </div> <bR> <div> <B>Indications for Echocardiography in Hypertension Class</B> </div> <bR> <div> 1. When assessment of resting LV function, hypertrophy, or concentric remodeling is important in clinical decision making (see LV function). I 2. Detection and assessment of functional significance of concomitant coronary artery disease (see coronary disease).<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Follow-up assessment of LV size and function in patients with LV dysfunction when there has been a documented change in clinical status or to guide medical therapy. I 4. Identification of LV diastolic filling abnormalities with or without systolic abnormalities. IIa 5. Assessment of LV hypertrophy in a patient with borderline hypertension without LV hypertrophy on ECG to guide decision making regarding initiation of therapy. A limited goal-directed echocardiogram may be indicated for this purpose. IIa 6. Risk stratification for prognosis by determination of LV performance. IIb 7. Reevaluation to guide antihypertensive therapy based on LV mass regression. III 8. Reevaluation in asymptomatic patients to assess LV function. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>Stress echocardiography. </div> <bR> <div> <B>Indications for Echocardiography in Patients With Neurological Events or Other Vascular Occlusive Events Class</B> </div> <bR> <div> 1. Patients of any age with abrupt occlusion of a major peripheral or visceral artery. I 2. Younger patients (typically <45 years) with cerebrovascular events. I 3. Older patients (typically >45 years) with neurological events without evidence of cerebrovascular disease or other obvious cause. I 4. Patients for whom a clinical therapeutic decision (anticoagulation, etc) will depend on the results of echocardiography. I 5. Patients with suspicion of embolic disease and with cerebrovascular disease of questionable significance. IIa 6. Patients with a neurological event and intrinsic cerebrovascular disease of a nature sufficient to cause the clinical event. IIb 7. Patients for whom the results of echocardiography will not impact a decision to institute anticoagulant therapy or otherwise alter the approach to diagnosis or treatment. III </div> <bR> <div> <B>Indications for Echocardiography in Patients With Arrhythmias and Palpitations Class</B> </div> <bR> <div> 1. Arrhythmias with clinical suspicion of structural heart disease. I 2. Arrhythmia in a patient with a family history of a genetically transmitted cardiac lesion associated with arrhythmia such as tuberous sclerosis, rhabdomyoma, or hypertrophic cardiomyopathy. I 3. Evaluation of patients as a component of the workup before electrophysiological ablative procedures. I 4. Arrhythmia requiring treatment. IIa 5. TEE guidance of transseptal catheterization and catheter placement during ablative procedures. IIa 6. Arrhythmias commonly associated with, but without clinical evidence of, heart disease. IIb 7. Evaluation of patients who have undergone radiofrequency ablation in the absence of complications. (In centers with established ablation programs, a postprocedural echocardiogram may not be necessary. ) IIb 8. Palpitation without corresponding arrhythmia or other cardiac signs or symptoms. III 9. Isolated premature ventricular contractions for which there is no clinical suspicion of heart disease. III </div> <bR> <div> <B>Indications for Echocardiography Before Cardioversion Class</B> </div> <bR> <div> 1. Patients requiring urgent (not emergent) cardioversion for whom extended precardioversion anticoagulation is not desirable.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 2. Patients who have had prior cardioembolic events thought to be related to intra-atrial thrombus.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 3. Patients for whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 4. Patients for whom intra-atrial thrombus has been demonstrated in previous TEE.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> I 5. Evaluation of patient for whom a decision concerning cardioversion will be impacted by knowledge of prognostic factors (such as LV function, coexistent mitral valve disease, etc). I 6. Patients with atrial fibrillation of <48 hours' duration and other heart disease.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIa 7. Patients with atrial fibrillation of <48 hours' duration and no other heart disease.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIb 8. Patients with mitral valve disease or hypertrophic cardiomyopathy who have been on long-term anticoagulation at therapeutic levels before cardioversion.<FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT> IIb 9. Patients undergoing cardioversion from atrial flutter. IIb 10. Patients requiring emergent cardioversion. III 11. Patients who have been on long-term anticoagulation at therapeutic levels and who do not have mitral valve disease or hypertrophic cardiomyopathy before cardioversion. III 12. Precardioversion evaluation of patients who have undergone previous TEE and with no clinical suspicion of a significant interval change. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>TEE only. </div> <bR> <div> <B>Indications for Echocardiography in the Patient With Syncope Class</B> </div> <bR> <div> 1. Syncope in a patient with clinically suspected heart disease. I 2. Periexertional syncope. I 3. Syncope in a patient in a high-risk occupation (e.g., pilot). IIa 4. Syncope of occult etiology with no findings of heart disease on history or physical exam. IIb 5. Recurrent syncope in a patient in whom previous echocardiographic or other testing demonstrated a cause of syncope. III 6. Syncope in a patient for whom there is no clinical suspicion of heart disease. III 7. Classic neurogenic syncope. III </div> <bR> <div> <B>Indications for Echocardiography to Screen for the Presence of Cardiovascular Disease Class</B> </div> <bR> <div> 1. Patients with a family history of genetically transmitted cardiovascular disease. I 2. Potential donors for cardiac transplantation. I 3. Patients with phenotypic features of Marfan syndrome or related connective tissue diseases. I 4. Baseline and reevaluations of patients undergoing chemotherapy with cardiotoxic agents. I 5. Patients with systemic disease that may affect the heart. IIb 6. The general population. III 7. Competitive athletes without clinical evidence of heart disease. III </div> <bR> <div> <B>Conditions and Settings in Which Transesophageal Echocardiography Provides the Most Definitive Diagnosis in the Critically Ill and Injured</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The hemodynamically unstable patient with suboptimal TTE images. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The hemodynamically unstable patient on a ventilator. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Major trauma or postoperative patients (unable to be positioned for adequate TTE). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Suspected aortic dissection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Suspected aortic injury. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other conditions in which TEE is superior (see section on valvular disease). </div> <bR> <div> <B>Indications for Echocardiography in the Critically Ill Class</B> </div> <bR> <div> 1. The hemodynamically unstable patient. I 2. Suspected aortic dissection (TEE). I 3. The hemodynamically stable patient not expected to have cardiac disease. III 4. Reevaluation follow-up studies on hemodynamically stable patients. III </div> <bR> <div> <B>Indications for Echocardiography in the Critically Injured</B><FONT SIZE="1" COLOR="#000000" FACE="arial" ><B>*</B></FONT><B> Class</B> </div> <bR> <div> 1. Serious blunt or penetrating chest trauma (suspected pericardial effusion or tamponade). I 2. Mechanically ventilated multiple-trauma or chest trauma patient. I 3. Suspected preexisting valvular or myocardial disease in the trauma patient. I 4. The hemodynamically unstable multiple-injury patient without obvious chest trauma but with a mechanism of injury suggesting potential cardiac or aortic injury (deceleration or crush). I 5. Widening of the mediastinum, postinjury suspected aortic injury (TEE). I 6. Potential catheter, guidewire, pacer electrode, or pericardiocentesis needle injury with or without signs of tamponade. I 7. Evaluation of hemodynamics in multiple-trauma or chest trauma patients with pulmonary artery catheter monitoring and data disparate with clinical situation. IIa 8. Follow-up study on victims of serious blunt or penetrating trauma. IIa 9. Suspected myocardial contusion in the hemodynamically stable patient with a normal ECG. III <FONT SIZE="1" COLOR="#000000" FACE="arial" >*</FONT>The use of TTE or TEE includes Doppler techniques when indicated and available and with appropriately trained and experienced sonographer and interpreter. </div> <div> TEE is indicated when TTE images are suboptimal. TEE often provides incremental information. </div> <bR> <div> <B>Indications for Echocardiography in the Adult Patient With Congenital Heart Disease Class</B> </div> <bR> <div> 1. Patients with clinically suspected congenital heart disease, as evidenced by signs and symptoms such as a murmur, cyanosis, or unexplained arterial desaturation, and an abnormal ECG or radiograph suggesting congenital heart disease. I 2. Patients with known congenital heart disease on follow-up when there is a change in clinical findings. I 3. Patients with known congenital heart disease for whom there is uncertainty as to the original diagnosis or when the precise nature of the structural abnormalities or hemodynamics is unclear. I 4. Periodic echocardiograms in patients with known congenital heart lesions and for whom ventricular function and atrioventricular valve regurgitation must be followed (e.g., patients with a functionally single ventricle after Fontan procedure, transposition of the great vessels after Mustard procedure, l-transposition and ventricular inversion, and palliative shunts). I 5. Patients with known congenital heart disease for whom following pulmonary artery pressure is important (e.g., patients with moderate or ventricular septal defects, atrial septal defects, single ventricle, or any of the above with an additional risk factor for pulmonary hypertension). I 6. Periodic echocardiography in patients with surgically repaired (or palliated) congenital heart disease with the following: change in clinical condition or clinical suspicion of residual defects, LV or RV function that must be followed, or when there is a possibility of hemodynamic progression or a history of pulmonary hypertension. I 7. To direct interventional catheter valvotomy, radiofrequency ablation valvotomy interventions in the presence of complex cardiac anatomy. I 8. A follow-up Doppler echocardiographic study, annually or once every 2 years, in patients with known hemodynamically significant congenital heart disease without evident change in clinical condition. IIb 9. Multiple repeat Doppler echocardiography in patients with repaired patent ductus arteriosus, atrial septal defect, ventricular septal defect, coarctation of the aorta, or bicuspid aortic valve without change in clinical condition. III 10. Repeat Doppler echocardiography in patients with known hemodynamically insignificant congenital heart lesions (e.g., small atrial septal defect, small ventricular septal defect) without a change in clinical condition. III </div> <bR> <div> <B>Indications for Neonatal Echocardiography Class</B> </div> <bR> <div> 1. Cyanosis, respiratory distress, congestive heart failure, or abnormal arterial pulses. I 2. Chromosomal abnormality or major extracardiac abnormality associated with a high incidence of coexisting cardiac abnormality. I 3. Lack of expected improvement in cardiopulmonary status in a premature infant with a clinical diagnosis of pulmonary disease. I 4. Systemic maternal disease associated with neonatal comorbidity. I 5. Loud or abnormal murmur or other abnormal cardiac finding in an infant. I 6. Presence of a syndrome associated with cardiovascular disease and dominant inheritance or multiple affected family members. I 7. Presence of a syndrome associated with heart disease, with or without abnormal cardiac findings, for which an urgent management decision is needed. I 8. Cardiomegaly on chest radiograph. I 9. Dextrocardia, abnormal pulmonary or visceral situs by clinical, electrocardiographic, or radiographic examination. I 10. Arrhythmias or other abnormalities on standard ECG suggesting structural heart disease or peripartum myocardial injury. I 11. Clinical suspicion of residual or recurrent abnormality, poor ventricular function, pulmonary artery hypertension, thrombus, sepsis, or pericardial effusion after cardiovascular surgical therapy for congenital heart disease. I 12. Nonimmunologic fetal hydrops. I 13. Follow-up assessment of a neonate with patent ductus arteriosus who has undergone medical or surgical intervention. I 14. Short, soft murmur at the lower left sternal border in the neonate. IIa 15. Failure to thrive in the absence of definite abnormal clinical findings. IIa 16. 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. IIb 17. History of nonsustained fetal ectopy in the absence of postpartum arrhythmias. III </div> <bR> <div> <B>Indications for Echocardiography in the Infant, Child, and Adolescent Class</B> </div> <bR> <div> 1. Atypical or pathological murmur or other abnormal cardiac finding in an infant or older child. I 2. Cardiomegaly on chest radiograph. I 3. Dextrocardia, abnormal pulmonary or visceral situs on clinical, electrocardiographic, or radiographic examination. I 4. Patients with a known cardiac defect to assess timing of medical or surgical therapy. I 5. Immediate preoperative evaluation for cardiac surgery of a patient with a known cardiac defect to guide cardiac surgical management and inform the patient and family of risks of surgery. I 6. Patient with known cardiac lesion and change in physical finding. I 7. Postoperative congenital or acquired heart disease with clinical suspicion of residual or recurrent abnormality, poor ventricular function, pulmonary artery hypertension, thrombus, sepsis, or pericardial effusion. I 8. Presence of a syndrome associated with cardiovascular disease and dominant inheritance or multiple affected family members. I 9. Patients with a family history of genetically transmitted myocardial disease, with or without abnormal cardiac finding. I 10. Phenotypic findings of Marfan syndrome or Ehlers-Danlos syndrome. I 11. Baseline and follow-up examinations of patients with neuromuscular disorders having known myocardial involvement. I 12. Presence of a syndrome associated with a high incidence of congenital heart disease when there are no abnormal cardiac findings. I 13. Exercise-induced precordial chest pain or syncope. I 14. "Atypical," "non-vasodepressor" syncope without other cause. I 15. Failure to thrive in the absence of definite abnormal clinical findings. IIb 16. In a child or adolescent, an asymptomatic heart murmur identified by an experienced observer as functional or an insignificant cardiovascular abnormality. III 17. In an otherwise asymptomatic child or adolescent, chest pain identified by an experienced observer as musculoskeletal in origin. III </div> <bR> <div> <B>Indications for Echocardiography in Pediatric Patients With Arrhythmias/Conduction Disturbances Class</B> </div> <bR> <div> 1. Arrhythmia in the presence of an abnormal cardiac finding. I 2. Arrhythmia in a patient with a family history of a genetically transmitted cardiac lesion associated with arrhythmia, such as tuberous sclerosis or hypertrophic cardiomyopathy. I 3. Complete atrioventricular block or advanced second-degree atrioventricular block. I 4. Complete or high-degree secondary atrioventricular block. I 5. Arrhythmia requiring treatment. I 6. Ventricular arrhythmia in a patient referred for evaluation for competitive sports. IIa 7. Evidence of preexcitation on ECG. IIa 8. Preexcitation on ECG in the absence of abnormal cardiac findings. IIb 9. Recurring arrhythmia not requiring treatment in the presence of normal findings on examination. IIb 10. Sinus arrhythmia or isolated extrasystoles in a child with otherwise normal cardiac findings and no family history of a genetically transmitted abnormality associated with arrhythmia. III </div> <bR> <div> <B>Indications for Echocardiography in Pediatric Acquired Cardiovascular Disease Class</B> </div> <bR> <div> 1. Baseline studies and reevaluation as clinically indicated on all pediatric patients with suspected or documented Kawasaki disease, myopericarditis, HIV, or rheumatic fever. I 2. Postcardiac or cardiopulmonary transplant to monitor for signs of acute or chronic rejection, thrombus, and cardiac growth. I 3. Baseline and reevaluation examinations of patients receiving cardiotoxic therapeutic agents. I 4. Patients with clinical evidence of myocardial disease. I 5. Patients with severe renal disease and an abnormal cardiac finding. I 6. Donors undergoing evaluation for cardiac transplantation. I 7. An acutely ill child with suspected bacterial sepsis or rickettsial disease. IIa 8. Follow-up examinations after acute rheumatic fever in patients with normal cardiac findings. IIb 9. A single late follow-up study after acute pericarditis with no evidence of recurrence or chronic pericardial disease. IIb 10. Long-term follow-up studies in patients with Kawasaki disease who have no coronary abnormalities during the acute phase of the disease process. III </div> <bR> <div> <B>Indications for Echocardiography in Pediatric Cardiopulmonary Disease Class</B> </div> <bR> <div> 1. Any patient with clinical findings of pulmonary artery hypertension. I 2. Baseline study of patients with cystic fibrosis and no findings of cor pulmonale. IIa </div> <bR> <div> <B>Indications for Echocardiography in Pediatric Thromboembolic Disease States Class</B> </div> <bR> <div> 1. Thromboembolic event in an infant, child, or adolescent. I 2. Finding or family history of tuberous sclerosis. I 3. Appearance of sepsis, cyanosis, or right-heart failure in a patient with a long-standing indwelling catheter. I 4. Systemic embolization or acute-onset hypertension in a patient with right-to-left-shunting and an indwelling catheter. I 5. Superior vena caval syndrome in the presence of central venous catheter. I 6. Patient with indwelling catheter and fever but without evidence of pulmonary or systemic embolization. IIb 7. Routine surveillance of asymptomatic patients with indwelling catheter. III </div> <bR> <div> <B>Indications for Transesophageal Echocardiography in Pediatric Patients Class</B> </div> <bR> <div> 1. Any patient with congenital or acquired heart disease needing echocardiography when significant diagnostic information cannot be obtained by TTE. I 2. Monitoring and guidance during cardiothoracic procedures when there is a risk for residual shunting, valvular insufficiency, obstruction, or myocardial dysfunction. I 3. Guidance of catheter/device placement during interventional catheterization/radiofrequency ablation in patients with congenital heart disease. I 4. Study of patients with intra-atrial baffle in whom the potential for thrombus is of concern because of elevated central venous pressures, atrial chamber dilation, increasing cyanosis, or the appearance of arrhythmia. I 5. Patients with long-term placement of intravascular devices in whom thrombus or vegetation is suspected. I 6. Patients with a prosthetic valve in whom thrombus or vegetation is suspected. I 7. Any patient with suspected endocarditis and inadequate transthoracic acoustical window. I 8. Performing TEE in a patient who has not previously had careful study by TTE. III 9. Patients with structural esophageal abnormality. III </div> <bR> <div> <B>Indications for Fetal Echocardiography Class</B> </div> <bR> <div> 1. Abnormal-appearing heart on general fetal ultrasound examination. I 2. Fetal tachycardia, bradycardia, or persistent irregular rhythm on clinical or screening ultrasound examination. I 3. Maternal/family risk factors for cardiovascular disease, such as a parent, sibling, or first-degree relative with congenital heart disease. I 4. Maternal diabetes. I 5. Maternal systemic lupus erythematosus. I 6. Teratogen exposure during a vulnerable period. I 7. Other fetal system abnormalities (including chromosomal). I 8. Performance of transplacental therapy or presence of a history of significant but intermittent arrhythmia. Reevaluation examinations are required in these conditions. I 9. Fetal distress or dysfunction of unclear etiology. IIa 10. Previous history of multiple fetal losses. IIb 11. Multiple gestation. IIb 12. Low-risk pregnancies with normal anatomic findings on ultrasound examination. III 13. Occasional premature contractions without sustained tachycardia or signs of dysfunction or distress. III 14. Presence of a noncardiovascular system abnormality when evaluation of the cardiovascular system will not alter either management decisions or fetal outcome. III </div> <bR> <bR> <bR> </td> </tr></table></body>