CME Information: 2.0 Credits, 2.0 ABIM MOC Points
CME Expiration Date: April 30, 2018
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Session Exam APR.17 - Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation Speaker(s): William A. Zoghbi, MD, FASE Robert O. Bonow, MD Maurice Sarano, MD Elyse Foster, MD, FASE Paul A. Grayburn, MD, FASE Rebecca T. Hahn, MD, FASE Yuchi Han Judy W. Hung, MD, FASE Roberto M. Lang, MD, FASE Stephen H. Little, MD, FASE Dipan Shah, MD Stanton Shernan, MD, FASE Paaladinesh Thavendiranathan, MD, FASE James D. Thomas, MD, FASE Neil J. Weissman, MD, FASE David Adams, MD * - Indicates answer is required. * Please choose your certificate type: Physician Non-Physician 1) ABIM Number (Required for transfer to ABIM) ARDMS 11879 2) Birthdate (MM/DD required for transfer to ABIM) 06/29/50 Please rate the impact of the following objectives: As a result of attending this activity, I am better able to: *3) Define the severity, mechanism, etiology, and impact of valvular regurgitation Strongly Agree Agree Neutral Disagree Strongly Disagree *4) Apply the principles of comprehensive imaging, integrative interpretation, individualization, and precise language to the echocardiographic evaluation of valvular regurgitation Strongly Agree Agree Neutral Disagree Strongly Disagree *5) Focus attention on the three components of the regurgitant jet by color Doppler -flow convergence, vena contracta, and jet area -to improve overall accuracy of assessment of regurgitation severity Strongly Agree Agree Neutral Disagree Strongly Disagree *6) Identify the determinants of the flow characteristics and dynamics of spectral (PW and CW) Doppler in valvular regurgitation Strongly Agree Agree Neutral Disagree Strongly Disagree *7) Appreciate the strengths and limitations of CMR in the evaluation of valvular regurgitation Strongly Agree Agree Neutral Disagree Strongly Disagree Please rate the projected impact of this activity on your competence, performance, and patient outcomes*: Note: competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something). *8) This activity increased my competence. Strongly Agree Agree Neutral Disagree Strongly Disagree *9) This activity improved my performance. Strongly Agree Agree Neutral Disagree Strongly Disagree *10) This activity will improve my patient outcomes. Strongly Agree Agree Neutral Disagree Strongly Disagree Please provide us with feedback on the Activity content: *11) The activity content matched my current (or potential) scope of practice. Strongly Agree Agree Neutral Disagree Strongly Disagree *12) The activity presented objective, balanced and scientifically rigorous content and was free from commercial bias. Strongly Agree Agree Neutral Disagree Strongly Disagree *13) The educational format was appropriate for the topic/educational objectives. Strongly Agree Agree Neutral Disagree Strongly Disagree *14) Author disclosure was provided. Strongly Agree Agree Neutral Disagree Strongly Disagree *15) Authors were appropriate for the activity. Strongly Agree Agree Neutral Disagree Strongly Disagree 16) If you felt the activity contained commercial bias, please explain: no 17) Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core competencies were addressed by this educational activity (select all that apply): Patient care or patient-centered care System-based practice Interpersonal and communication skills Practice-based learning & improvement Professionalism Employ evidence-based practice Interdisciplinary teams Quality improvement Utilize informatics Medical knowledge None of the above 18) What changes, if any, do you plan to make in your practice as a result of this activity? na 19) Please indicate any potential barriers that may affect the implementation of these changes. Cost Lack of experience Lack of opportunity Lack of resources/equipment Lack of administrative support Lack of qualified/trained staff Lack of time to assess patients Reimbursement/insurance issues Lack of consensus or professional guidelines No Barriers Other, please specify: 20) Please indicate what knowledge gaps, practice gaps or patient health issues that you have encountered in your practice or profession that you would like to see addressed in CME activities. 21) What other topics would you like to see provided in an article format? Posttest Questions *22) Valvular regurgitation results from a variety of etiologies that prevent complete apposition of leaflets or cusps. These are grossly divided into organic and functional regurgitation. Which of the following does not represent primary regurgitation? Degeneration, inflammation, infection Trauma, tissue disruption Chamber remodeling Iatrogenic or congenital *23) Color flow Doppler is widely used for the detection of regurgitant lesions and is the primary method for assessment of regurgitation severity. Factors that may increase the color Doppler jet area include all but which of the following? Higher momentum Higher Nyquist limit Higher Doppler gain Multiple regurgitant orifices *24) The intensity (or amplitude) of the Continuous Wave (CW) regurgitant signal is proportional to the number of red cells reflecting the signal. Thus: A soft signal is indicative of severe regurgitation A dense signal can easily differentiate moderate from severe regurgitation A central jet well aligned with the ultrasound beam may appear denser than an eccentric jet of greater severity if not well aligned The signal density of CW Doppler is not dependent on spectral recording throughout the cardiac cycle *25) There are three methods for quantitative assessment of valvular regurgitation. The pulsed Doppler (PW) recording of VTI combined with the measurement of a valve annulus provides stroke volume(SV) at an individual site. In patients with no shunts or valve regurgitation, stroke volumes at different sites should be equal. In the presence of regurgitation of one valve, the SV through the affected valve is larger than through other competent valves. While this method is simple in principle, it is associated with potential for error and at least one major challenge, including all but which of the following? Each of the component stroke volumes has intrinsic error; these errors increase when the SVs are subtracted Failure to measure the valve annulus accurately (error is squared in the formula) and failure to trace the outer edge velocity of the PW tracing at the leaflet tips Failure to position the sample volume correctly at the level of the annulus and failure to trace the modal velocity of the PW tracing Failure to measure the valve annulus accurately, with incorrect positioning of the PW sample volume at the leaflet tips instead of at the annular level *26) The PISA - proximal isovelocity surface area - method is simple conceptually and has become the main method of quantification of regurgitation, particularly for AV valves. Several core principles requiring attention include all but which of the following? Timing of measurements - measurements of flow and velocity should be performed at simultaneous moments of the regurgitant phase The duration of regurgitation (eg, partial mid-late systole or functional MR in early systole and isovolumic relaxation) It is essential to aim for the largest flow convergence as it always times with the peak velocity of the regurgitation The shape of the PISA - the standard method assumes that the valvular plane from which the regurgitant orifice arises is planar and that the flow convergence is homogeneous, but this is not always the case *27) While there are multiple strengths of cardiac magnetic resonance imaging (CMR) in the evaluation of valvular regurgitation, limitations include (more than one answer may be correct) It cannot be performed in patients with certain implanted devices (eg defibrillators) The free choice of imaging planes limits the reliable comprehensive assessment of all four cardiac valves Volumetric assessment by CMR has been shown to have low interstudy reproducibility and hence limits reliable serial assessment There are no uniform thresholds for grading the severity of regurgitation and there is a paucity of outcome data available regarding specific thresholds A and D A and C *28) The most common cause of primary MR is myxomatous degeneration, most frequently mitral valve prolapse (MVP). Which of the following statements is true? Fibroelastic deficiency is diffuse thickening and redundancy of isolated scallops Fibroelastic deficiency is focal segmental pathology with thin leaflets Barlow's disease is focal segmental pathology with think leaflets and holosystolic MR Barlow's disease is diffuse thickening of limited scallops with late systolic MR *29) When evaluating MR with PW at the mitral leaflet tips, an E velocity of >1.2m/sec is a supportive sign of severe MR; a dominant A- wave inflow pattern virtually excludes severe MR. Which of the following does not impact the specificity of a high E velocity? Secondary MR Imaging with TEE Atrial fibrillation Mitral inflow stenosis *30) Doppler methods for the evaluation of MR include color (PISA,VC, jet area,3D VC), PW, CW, and quantitative Doppler (EROA, RVol, RF, PISA). Each has advantages and pitfalls. Which of the following is a pitfall of CW Doppler? Small errors in the radius measurement can lead to substantial errors in EROA A contour with an early peak velocity is not sensitive for severe MR Overestimation when MR is not holosystolic Dependent on hemodynamic (especially LV systolic pressure) and technical variables *31) Findings of a vena contracta (VC) width of >0.6cm, large flow convergence, a pressure half-time (PHT) of =0.7cm *33) Findings that are specific for severe pulmonary regurgitation (PR) include a dense jet and early termination of PR flow, with diastolic flow reversal in the pulmonary artery (PA) branches. In addition, a Doppler PR index has been suggested, which is The ratio of the duration of systolic flow to diastolic flow The ratio of the systolic TVI to the size of the PV annulus The ratio of the VCW to the PV annulus diameter The ratio of PR duration by CW Doppler to total diastolic time *34) The presence of multivalvular disease makes the assessment of valvular regurgitation more complex. All but which of the following are true? The addition of AS to MR will increase the RVol in proportion to the square root of the rise in pressure In the setting of severe AR, the mitral regurgitant orifice area in functional MR will change as the degree of coaptation can vary considerably with changes in LV volume PISA is substantially influenced by another regurgitant jet, especially AR, which commonly contaminates the flow convergence region of severe MR There should be little direct impact on VC from a second valvular lesion
Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance
CME Information: 2.0 credits
Release date: June 19, 2017 Valid through: April 30, 2018
Introduction/Statement of Need:
Valvular regurgitation continues to be an important cause of morbidity and mortality. While a careful history and physical examination remain essential in the overall evaluation and management of patients with suspected valvular disease, diagnostic methods are often needed and are crucial to assess the etiology and severity of valvular regurgitation, the associated remodeling of cardiac chambers in response to the volume overload, and the characterization of longitudinal changes for optimal timing of intervention. In 2003, the American Society of Echocardiography along with other endorsing organizations provided, for the first time, recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional (2D) and Doppler echocardiography. Advances in three-dimensional (3D) echocardiography and cardiovascular magnetic resonance (CMR) have occurred in the interim that provide additional tools to further delineate the pathophysiology and mechanisms of regurgitation and supplement current methods for assessing regurgitation severity.
This activity is designed for all cardiac sonographers and cardiovascular physicians with a primary interest and knowledge base in the field of echocardiography; in addition, residents, researchers, clinicians, intensivists, and other medical professionals with a specific interest in pediatric and congenital heart disease may find this activity beneficial.
At the end of this activity the reader will better be able to
The American Society of Echocardiography is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Echocardiography designates this enduring material for a maximum of 2.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
ARDMS, CCI and Sonography Canada recognize ASE’s certificates and have agreed to honor the credit hours toward their registry requirements for sonographers.
The American Society of Echocardiography is committed to ensuring that its educational mission and all sponsored educational programs are not influenced by the special interests of any corporation or individual, and its mandate is to retain only those authors whose financial interests can be effectively resolved to maintain the goals and educational integrity of the activity. While a monetary or professional affiliation with a corporation does not necessarily influence an author’s presentation, the Essential Areas and policies of the ACCME require that any relationships that could possibly conflict with the educational value of the activity be resolved prior to publication and disclosed to the audience. Disclosures of faculty and commercial support relationships, if any, have been indicated.
William A. Zoghbi, MD, FASE (Chair), David Adams, RCS, RDCS, FASE, Robert O. Bonow, MD, Maurice Enriquez-Sarano, MD, Elyse Foster, MD, FASE, Paul A. Grayburn, MD, FASE, Rebecca T. Hahn, MD, FASE, Yuchi Han, MD, MMSc,* Judy Hung, MD, FASE, Roberto M. Lang, MD, FASE, Stephen H. Little, MD, FASE, Dipan J. Shah, MD, MMSc,* Stanton Shernan, MD, FASE, Paaladinesh Thavendiranathan, MD, MSc, FASE,* James D. Thomas, MD, FASE, and
Neil J. Weissman, MD, FASE
According to ACCME policy, ASE implemented mechanisms to resolve all conflicts of interest prior to the planning and implementation of this activity.
The following authors reported no actual or potential conflicts of interest in relation to this document:
David Adams, RCS, RDCS, FASE; Robert O. Bonow, MD; Judy Hung, MD, FASE; Stephen H. Little, MD, FASE; Paaladinesh Thavendiranathan, MD, MSc; and Neil J. Weissman, MD, FASE.
The following authors reported relationships with one or more commercial interests:
The following 2016-2017 ASE Board of Directors, Guidelines and Standards Committee and a representative for the Society for Cardiovascular Magnetic Resonance reviewed this document and reported no actual or potential conflicts of interest in relation to this document:
Reviewers included Deborah A. Agler, RCT, RDCS, FASE, Merri L. Bremer, EdD, RN, EDCS, ACS, FASE, Benjamin Byrd, MD, FASE, Hollie D. Carron, RDCS, FASE, Joao L. Cavalcante, MD, FASE, Scott D. Choyce, RDCS, RVT, RDMS, FASE, Frederick C. Cobey, MD, FASE, Patrick H. Collier, MD, PhD, FASE, Keith A. Collins, MS, RDCS, FASE, Mary C. Corretti, MD, FASE, Benjamin Eidem, MD, FASE, Mark K. Friedberg, MD, FASE, Neal Gerstein, MD, FASE, Edward A. Gill, MD, FASE, Yvonne E. Gilliland, MD, FASE, Robi Goswami, MD, FASE, Lanqi Hua, RDCS, FASE, James N. Kirkpatrick, MD, FASE, Jonathan R. Lindner, MD, FASE, Rick Meece, ACS, RDCS, RCIS, FASE, Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R), ACS, FASE, Maryellen H. Orsinelli, RN, RDCS, FASE, Andy Pellett, PhD, RCS, RDCS, FASE, Patricia A. Pellikka, MD, FASE, Sue D. Phillip, RCS, FASE, Juan Carlos Plana, MD, FASE, Vera H. Rigolin, MD, FASE, Vandana Sachdev, MD, FASE, Anita Sadeghpour, MD, FASE, Liza Y. Sanchez, RCS, FASE, Elaine Shea, ACS, RCS, RCCS, FASE, Roman M. Sniecinski, MD, FASE, Raymond F. Stainback, MD, FASE, Cynthia Taub, MD, FASE, Seth Uretsky, MD, Neil J. Weissman, MD, FASE, and David H. Wiener, MD, FASE.
The following board and guidelines and standards committee members reported relationships with one or more commercial interests:
Frederico Asch, MD, FASE- Medtronic (Research Grant Support); St. Jude Medical (Research Grant Support); Biotronik (Research Grant Support); Sorin Group (Research Grant Support); Boston Scientific (Research Grant Support); Edwards Lifesciences (Research Grant Support); Abbott Vascular (Research Grant Support); Mitralign (Research Grant Support); Direct Flow (Research Grant Support); Xaltis (Research Grant Support); Meryl Cohen, MD, FASE - Johnson & Johnson (Stock Ownership); Pfizer (Stock Ownership); Stephen Heitner, MD, FASE- Johnson & Johnson (Stock Ownership); Millennium Pharmaceuticals (Consultant/ Advisor); Onyx pharmaceuticals (Consultant/ Advisor); Soo Kim, MD, MPH, RPVI, FASE- Philips Ultrasound (Consultant/ Advisor); Allan Klein, MD, FASE -Bayer (Steering Committee);Stamatios Lerakis, MD, FASE- Edwards Lifesciences (Consultant/ Advisor); Stephen Little, MD, FASE- St. Jude Medical (Research Grant Support); Abbott Structural (Research Grant Support); Medtronic (Research Grant Support); Tasneen Naqvi, MD, FASE- Adagio Medical (Stock Ownership); Panasonic CardioHealth Station (Research Grant Support); Lawrence Rudski, MD, FASE- GE (Stock Ownership); Roman Sniecinski, MD, FASE- Grifols Therapeutics (Consultant/ Advisor); Steven Walling, RCS, RDCS, FASE- Lantheus (Speaker/ Speakers Bureau) (Consultant/Advisor); Susan Wiegers MD, FASE- Merck (Stock Ownership); Covance (Spouse Employment)
The following ACCME reviewers, ASE Staff and CME editors reported no actual or potential conflicts of interest in relation to this document:
Pricilla Peters, BA, RDCS, FASE, Alina Nicoara, MD, FASE, Renee Bullock-Palmer, MD, FASE, Rhonda Price, Mary Lawson, and Christina LaFuria
The following ACCME reviewers, ASE Staff and CME editors reported relationships with one or more commercial interests:
Method of Participation: Online Only
Estimated Time to Complete this Activity: 2.0 hours
Receiving CME Credit:
To receive online CME credit for this activity, read the full activity then complete the posttest and evaluation. A score of 70% or higher is required for successful completion. You will be able to print your CME certificate immediately following successful completion of the posttest and evaluation.
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This report is made available by ASE as a courtesy reference source for members. This report contains recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in this report are primarily based on the opinions of experts, rather than on scientifically verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in this report, including the warranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician patient relationship between ASE and your patients or anyone else.
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