17th Annual Echo in the Slopes
May 16-17, 2015
Boyne Mountain
A weekend wrap-up by Dr. Felix Rogers
What does it take to be great? Queen Elizabeth I famously said that she could be placed anywhere in England wearing nothing but a petticoat and rise to be the Queen. In a similar vein, you could probably drop the Michigan Society of Echocardiography anywhere in Michigan, any season or weather, and Echo in the Slopes would still be the best chapter meeting anywhere.
This year’s program focused on guideline updates, practical approaches to complex topics and challenged us to go beyond the usual approaches in order to expand and integrate our skill set.
The opening presentation was actually a three part approach to stress echocardiography, taking us beyond the usual focus on detection of ischemic heart disease. Leading off, Nathan Kerner, MD, examined the subtleties of borderline valve gradients in the context of low or normal ventricular function. He provided recommendations that also included the use of CT imaging. Luis Afonso, MBBS, President-elect of the MSE, followed that with an incisive exploration of stress testing for patients with mitral stenosis. Hemodynamic stress testing for this condition is rare, and calls for an understanding of cardiac and pulmonary hemodynamics.
Then, MSE President, Dr. Karthik Ananth took us into the realm of stress testing for patients with ischemic mitral regurgitation. The first paradigm shift is to define severe disease with an effective regurgitant orifice greater than 0.2 cm2. The next is to assess the mitral valve in terms of the mitral annulus, the tented area under the leaflets, and the coaptation length.
Changing gears, Gerald Cohen, MD, proved to be a model professor. He led off with a pre-test, walked us through the necessary information for us to get the answers, and then reviewed the test results with us. We all swaggered out with a firm grasp of constrictive pericarditis.
Given the challenges of reviewing nearly 30 pages of guidelines on chamber quantitation, Felix Rogers, DO sided with the dilemma faced by Elizabeth Taylor’s seventh husband on their wedding night: He knew exactly what to do, but didn't know how to make it interesting. Felix narrowed the topic to look at the aorta, left ventricular dimensions and the left atrium. One key feature is that these guidelines have been harmonized with recommendations and guidelines from other societies. The echo findings are now an integral part of the clinical approach to topics that includes assessment for heart failure with preserved EF, management of patients with cancer/chemotherapy and surveillance of patients for thoracic aortic aneurysm.
While the case presentations for Stump the Stars were lively and entertaining, nobody was fooled. Our expert panel of Doctors Afonso, Ananth, and Michael Gallagher, MD deftly handled cases related to artifact simulating potential sources of cardioembolic stroke, critical tricuspid regurgitation, and complex congenital heart disease in the adult.
Sunday
Is it possible to rely on statistics to make your point, stay completely evidence-based, and still be interesting? It is if you are John Gorcsan, MD, Chair of the Department of Echo at U Pittsburgh and MSE Echo Jeopardy Host. With wit and humor, he simplified complex challenges so that everyone in the audience was able to understand his points and stay awake. He almost lost us when showed a Kaplan Meier Plot and a Hazard Ratio Plot, explaining how these can be used to make evidence based decisions. He pointed out that at the present time there is no definitive evidence for the use of closure devices and the only evidence-based therapy for aortic atheroma is the use of statins.
Rick Humes, MD, discussed postoperative congenital heart disease in adults. As only he can do, he organized a complex subject in a manner that was understandable to all. As usual, there was an abundance of common sense and logic. He emphasized the importance of knowing what was done and getting the operative report, pointing out that procedures generally fall under closing shunts, opening obstructions, decreasing pulmonary flow or increasing pulmonary flow, as well as the Fontan procedure. He pointed out that an echocardiogram of a VSD or ASD corrected in childhood may look normal in adults. Finally, he educated us on anatomic correction procedures including tetralogy, D-Transposition and single ventricle. In closing, he reminded us that in palliative procedures to focus on pulmonary artery flow.
Pat Bailey spoke on image optimization, and showed why she is one of the premier sonographers in Michigan, as she demonstrated numerous tips on how to improve images. She showed multiple examples illustrating the importance of depth, dynamic range, gain, focal zone, and others as part of a dazzling display of knobology. She also showed a picture of herself sitting next to one of the very early M-mode echo machines at the beginning of her career, which left some of the males in the audience in awe, and not over the 4 tier echo machine. Her talk was commended as being of value not only to sonographers, but also to physicians, especially those preparing for board certification.
The planning committee left it to Bill Armstrong, MD, to provide an update on the 2014 valve guidelines. He selected highlights from this lengthy document, including the importance of establishing of a heart valve team and center of excellence, stages of heart disease, exercise testing, TAVR, aortic stenosis, primary and secondary mitral regurgitation, preoperative risk assessment, and anticoagulation strategies for surgical patients with mechanical valves. As in all of his talks, there was a strong mix of common sense and humor-most of it appropriate.
Case presentations
The conference closed with the presentation of interesting cases demonstrating the value of multimodality imaging. Dr. Forst, who moderated the session, was smart enough to introduce the participants and then sit back and allow MSE’s finest to regale the audience.
Dr. Ananth showed a case of dense calcification of the mitral annulus and the left ventricle which he referred to as “a big MAC.” His second case showed a hypertrophic cardiomyopathy with mid ventricular obstruction and the development of an apical left ventricular aneurysm due to myocardial necrosis.
The new MSE President, Dr. Luis Afonso, showed a challenging case in a pre-renal transplant patient who was found to have an occluded subclavian vein with dramatic venous collateralization.
Dr. Cohen showed a case of an angiosarcoma in the right atrium in a very young woman.
Dr. Michael Gallagher closed the conference with a fascinating case of constrictive pericarditis, cementing the lessons taught by Dr. Cohen the preceding day. These adult cases were so interesting that even our pediatrician, Dr. Humes, got engaged in the conversation. Perhaps even more noteworthy, nobody left early.
Our beloved senior advisor, David Forst, MD, offered this take on this conference: it was one of the best we’ve ever had. It continued to build and the second day was uniformly excellent, finishing very strong. Concerning echo jeopardy, Pat Bailey carried Bill Armstrong to victory, outlasting the Moran/ Cohen and Uriarte/Forst teams, with no one correctly answering the final jeopardy question. Host John Gorscan was his usual dynamic self, the cases were mysterious and educational, and the advertisements remained a highlight. Feedback was very positive except that we had to endure an otherwise dignified echo guru doing the Hawaiian War Chant, or whatever that was, during the playing of the past national ASE Echo Jeopardy Dance Video, which was presented prior to the start of our competition.
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