CME Information: 1.0 Credits
ABIM MOC: 1.0 Credits
Expiration Date: June 30, 2020
You must be logged in and own this product in order to post comments.
“2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document:
A Proposal to Optimize Care for Patients with Valvular Heart Disease”
CME Information: 1 credit
Release date: June 2019 Valid through: June 2020
Introduction/Statement of Need:
The intent of this document is to propose a system of care for patients with VHD, the primary goal of which would be to optimize outcomes for all patients and ultimately improve the care of VHD at all centers. This approach is intended to increase the identification of patients with VHD and emphasize best practices as captured in the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease 2 and the 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.25 It is also intended to promote the efficient utilization of resources, facilitate communication and continuity of care, and emphasize the need for transparency in reporting of and accountability for outcomes relative to national benchmarks. The standards proposed for the optimal structure and function of valve centers, as well as key processes of care, mirror those in a companion 2018 AATS/ACC/SCAI/ STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement document.26 An interconnected system of providers and institutions may help strike the right balance between access and quality outcomes. The case for centers with the ability to offer more comprehensive care is logical, but it is critically important that patients and referring clinicians be made aware of the quality of care delivered in all centers. A major priority in optimizing VHD patient care is to identify and support centers with excellent outcomes and improve outcomes at centers where opportunities exist, not simply to promote those centers with good reputations or large procedural volumes.
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.
At the end of this article 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 AMA PRA Category 1 CreditsTM. 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 X MOC point in the American Board of Internal Medicine's (ABIM). 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.
Writing Group Members: Rick A. Nishimura, MD, MACC, Co-Chair, Patrick T. O’Gara, MD, MACC, Co-Chair, Joseph E. Bavaria, MD, FACC, Ralph G. Brindis, MD, MPH, MACC, FSCAI, John D. Carroll, MD, FACC, MSCAI, Clifford J. Kavinsky, MD, PhD, FACC, MSCAI, Brian R. Lindman, MD, MSc, FACC, Jane A. Linderbaum, RN, MS, APRN, CNP, AACC, Stephen H. Little, MD, FACC, FASE, Michael J. Mack, MD, FACC, Laura Mauri, MD, MSc, FACC, William R. Miranda, MD, David M. Shahian, MD, FACC, FACS, and Thoralf M. Sundt, III, MD, FACC
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:
Rick A. Nishimura, MD, MACC, Co-Chair, Patrick T. O’Gara, MD, MACC, Co-Chair, Ralph G. Brindis, MD, MPH, MACC, FSCAI, Clifford J. Kavinsky, MD, PhD, FACC, MSCAI, Jane A. Linderbaum, RN, MS, APRN, CNP, AACC, William R. Miranda, MD, David M. Shahian, MD, FACC, FACS, and Thoralf M. Sundt, III, MD, FACC
The following authors reported relationships with one or more commercial interests:
Joseph E. Bavaria, MD, FACC reported personal research with Edwards Lifesciences, Medtronic, Medtronic Vascular, St. Jude Medical, Vascutek, W.L. Gore, and working with Edwards Lifesciences and Medtronic for other financial benefit. John D. Carroll, MD, FACC, MSCAI reported personal research with Direct Flow, Edwards Lifesciences, Evalve/Abbott Structural Heart, Medtronic, St. Jude Medical, Teledyne (DSMB), and working with St. Jude Medical for other financial benefit, Brian R. Lindman, MD, MSc, FACC reported serving as a consultant with Roche Diagnostics and Medtronic as well as personal research with Edwards Lifesciences and Roche Diagnostics, Stephen H. Little, MD, FACC, FASE reported personal research with Abbott Laboratories, and Medtronic, Michael J. Mack, MD, FACC reported personal research with Abbott Vascular, Edwards Lifesciences, and Medtronic, Laura Mauri, MD, MSc, FACC reported serving as a consultant with Biotronik, Corvia, and St. Jude Medical, as well as working with Abbott Vascular, Biotronik, Boston Scientific, and Corvia in personal research
The following CME reviewers, ASE Staff and JASE editors reported no actual or potential conflicts of interest in relation to this document:
Andra Duncan, MD, MS, FASE, Hedda Richards, MD, FASE, Elizabeth Lane, and Christina LaFuria
The following CME reviewers, ASE Staff and JASE editors reported relationships with one or more commercial interests:
Method of Participation: Online Only
Estimated Time to Complete this Activity: 2 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.
You will need a compatible browser like Mozilla FireFox, Google Chrome or safari to view the content. Internet Explorer may not work.
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.
Copyright American Society of Echocardiography. Questions? Contact us at email@example.com
1. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio–Thoracic Surgery (EACTS). Eur Heart J 2012;33:2451-96.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-185.
3. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez– Sarano M. Burden of valvular heart diseases: a population–based study. Lancet 2006;368:1005-11.
4. d’Arcy JL, Coffey S, Loudon MA, et al. Large–scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study. Eur Heart J 2016;37:3515-22.
5. Carroll JD. TAVR prognosis, aging, and the second TAVR tsunami: insights from France. J Am Coll Cardiol 2016;68:1648-50.
6. Lindroos M, Kupari M, Heikkila J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol 1993;21:1220-5.
7. Durko AP, Osnabrugge RL, Van Mieghem NM, et al. Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projections. Eur Heart J 2018;39:2635-42.
8. Bach DS, Awais M, Gurm HS, Kohnstamm S. Failure of guideline adherence for intervention in patients with severe mitral regurgitation. J Am Coll Cardiol 2009;54:860-5.
9. Bach DS, Siao D, Girard SE, Duvernoy C, McCallister BD Jr., Gualano SK. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk. Circ Cardiovasc Qual Outcomes 2009;2:533-9.
10. Wang A, Grayburn P, Foster JA, et al. Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel. Am Heart J 2016;172:70-9.
11. Iung B, Delgado V, Lazure P, et al. Educational needs and application of guidelines in the management of patients with mitral regurgitation. A European mixed–methods study. Eur Heart J 2018;39:1295-303.
12. Dziadzko V, Clavel MA, Dziadzko M, et al. Outcome and undertreatment of mitral regurgitation: a community cohort study. Lancet 2018; 391:960-9.
13. Jokinen JJ, Hippelainen MJ, Pitkanen OA, Hartikainen JE. Mitral valve replacement versus repair: propensity–adjusted survival and quality-oflife analysis. Ann Thorac Surg 2007;84:451-8.
14. Chikwe J, Goldstone AB, Passage J, et al. A propensity score–adjusted retrospective comparison of early and mid-term results of mitral valve repair versus replacement in octogenarians. Eur Heart J 2011;32:618-26.
15. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg 2007;31:267-75.
16. Bolling SF, Li S, O’Brien SM, Brennan JM, Prager RL, Gammie JS. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg 2010;90:1904-11. discussion 1912.
17. Chikwe J, Toyoda N, Anyanwu AC, et al. Relation of mitral valve surgery volume to repair rate, durability, and survival. J Am Coll Cardiol 2017;69: 2397-406.
18. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation 2007; 115:881-7.
19. Kilic A, Shah AS, Conte JV, Baumgartner WA, Yuh DD. Operative outcomes in mitral valve surgery: combined effect of surgeon and hospital volume in a population-based analysis. J Thorac Cardiovasc Surg 2013; 146:638-46.
20. Vassileva CM, Boley T, Markwell S, Hazelrigg S. Impact of hospital annual mitral procedural volume on mitral valve repair rates and mortality. J Heart Valve Dis 2012;21:41-7.
21. Badhwar V, Thourani VH, Ailawadi G, Mack M. Transcatheter mitral valve therapy: The event horizon. J Thorac Cardiovasc Surg 2016;152: 330-6.
22. Chatterjee S, Rankin JS, Gammie JS, et al. Isolated mitral valve surgery risk in 77,836 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg 2013;96:1587-94. discussion 1594-5.
23. Gammie JS, Sheng S, Griffith BP, et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2009;87:1431-7. discussion 1437-9.
24. Badhwar V, Rankin JS, Thourani VH, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2018 update on research: outcomes analysis, quality improvement, and patient safety. Ann Thorac Surg 2018;106:8-13.
25. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;70:252-89.
26. Bavaria JE, Tommaso CL, Carroll J, et al. ACC/AATS/SCAI/STS expert consensus systems of care document: operator and institutional requirements for transcatheter aortic valve replacement. J Am Coll Cardiol 2019;107:650-84.
27. AlbertsMJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke 2005;36:1597-616.
28. Sampalis JS, Lavoie A, Boukas S, et al. Trauma center designation: initial impact on trauma–related mortality. J Trauma 1995;39:232-7. discussion 237-9.
29. D’Agostino RS, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 update on outcomes and quality. Ann Thorac Surg 2016;101:24-32.
30. Shahian DM, He X, Jacobs JP, et al. The Society of Thoracic Surgeons Isolated Aortic Valve Replacement (AVR) Composite Score: a report of the STS Quality Measurement Task Force. Ann Thorac Surg 2012;94: 2166-71.
31. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2014;148:e1-132.
32. OttoCM, KumbhaniDJ, Alexander KP, et al. 2017ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2017;69:1313-46.
33. O’Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70:2421-49.
34. Bonow RO, Brown AS, Gillam LD, et al. ACC/AATS/AHA/ASE/ EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association forCardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;70:2566-98.
35. Douglas VC, Tong DC, Gillum LA, et al. Do the Brain Attack Coalition’s criteria for stroke centers improve care for ischemic stroke? Neurology 2005;64:422-7.
36. Optimal hospital resources for care of the seriously injured. Bull Am Coll Surg 1976;61:15-22.
37. Mullins RJ, Mann NC. Population-based research assessing the effectiveness of trauma systems. J Trauma 1999;47:S59-66.
38. Norwood S, Fernandez L, England J. The early effects of implementing American College of Surgeons level II criteria on transfer and survival rates at a rurally based community hospital. J Trauma 1995;39:240-4. discussion 244-5.
39. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283:3102-9.
40. Alberts MJ, Wechsler LR, Jensen ME, et al. Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition. Stroke 2013;44:3382-93.
41. Champion JK, Pories WJ. Centers of excellence for bariatric surgery. Surg Obes Relat Dis 2005;1:148-51.
42. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;1:485-510.
43. Edwards FH, CohenDJ, O’Brien SM, et al. Development and validation of a risk prediction model for in-hospital mortality after transcatheter aortic valve replacement. JAMA Cardiol 2016;1:46-52.
44. Lancellotti P, Rosenhek R, Pibarot P, et al. ESC Working Group on Valvular Heart Disease position paper––heart valve clinics: organization, structure, and experiences. Eur Heart J 2013;34:1597-606.
45. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78.
46. Xian Y, Holloway RG, Chan PS, et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA 2011;305: 373-80.
47. Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg 2014;260:504-8. discussion 508-9.
48. Azagury D, Morton JM. Bariatric surgery outcomes in US accredited vs non-accredited centers: a systematic review. J Am Coll Surg 2016;223: 469-77.
49. Jollis JG, Al–Khalidi HR, Roettig ML, et al. Regional systems of care demonstration project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016;134:365-74.
50. Pearlman AS, Ryan T, Picard MH, Douglas PS. Evolving trends in the use of echocardiography: a study of Medicare beneficiaries. J Am Coll Cardiol 2007;49:2283-91.
51. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/ HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2011;57:1126-66.
52. Perk G, Kronzon I. Interventional echocardiography in structural heart disease. Curr Cardiol Rep 2013;15:338.
53. AHRQ. The SHARE Approach. Available at: https://www.ahrq.gov/ professionals/education/curriculum-tools/shareddecisionmaking/index. html. Accessed July 30, 2018.
54. DCRI. DCRI 2017 Data Query. North Carolina Duke Clinical Research Institute, 2017.
55. Kavinsky CJ, PoulinMF, MackMJ. Training in structural heart disease: call to action. Circulation 2018;138:225-8.
56. Alli O, Rihal CS, Suri RM, et al. Learning curves for transfemoral transcatheter aortic valve replacement in the PARTNER-I trial: technical performance. Catheter Cardiovasc Interv 2016;87:154-62.
57. Tommaso CL. Learning curves for TAVR: not quite see one, do one teach one. Catheter Cardiovasc Interv 2016;87:163-4.
58. Minha S, Waksman R, Satler LP, et al. Learning curves for transfemoral transcatheter aortic valve replacement in the PARTNER-I trial: success and safety. Catheter Cardiovasc Interv 2016;87:165-75.
59. Carroll J, Vemulapalli S, Dai D, et al. The association between procedural experience for transcatheter aortic valve replacement and outcomes: insights from the STS/ACC TVT Registry. J Am Coll Cardiol 2017;70: 29-41.
60. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27.
61. Patel HJ, Herbert MA, Drake DH, et al. Aortic valve replacement: using a statewide cardiac surgical database identifies a procedural volume hinge point. Ann Thorac Surg 2013;96:1560-5. discussion 1565-6.
62. Dewey TM, Herbert MA, Ryan WH, et al. Influence of surgeon volume on outcomes with aortic valve replacement. Ann Thorac Surg 2012;93: 1107-12. discussion 1112-3.
63. McNeely C, Markwell S, Filson K, Hazelrigg S, Vassileva C. Effect of hospital volume on prosthesis use and mortality in aortic valve operations in the elderly. Ann Thorac Surg 2016;101:585-90.
64. Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume–outcome effect in cardiovascular surgery: the role of failure to rescue. JAMA Surgery 2014;149:119-23.
65. Khera R, Pandey A, Koshy T, et al. Role of Hospital Volumes in Identifying Low-Performing and High-Performing Aortic and Mitral Valve Surgical Centers in the United States. JAMA Cardiol 2017;2:1322-31.
66. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346: 1128-37.
67. Badhwar V, Rankin JS, He X, et al. The Society of Thoracic Surgeons mitral repair/replacement composite score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force. Ann Thorac Surg 2016;101: 2265-71.
Journal of the American Society of Echocardiography Volume 32 Number 6 Writing Committee 701
68. GillinovM, Mick S, Suri RM. The specialty of mitral valve repair. JAm Coll Cardiol 2017;69:2407-9.
69. Shahian DM, Grover FL, Prager RL, et al. The Society of Thoracic Surgeons voluntary public reporting initiative: the first 4 years. Ann Surg 2015;262:526-35. discussion 533-5.
70. Shahian DM, Jacobs JP, Badhwar V, D’Agostino RS, Bavaria JE, Prager RL. Risk aversion and public reporting. Part 1: observations from cardiac surgery and interventional cardiology. Ann Thorac Surg 2017;104:2093-101.
71. Shahian DM, Jacobs JP, Badhwar V, D’Agostino RS, Bavaria JE, Prager RL. Risk aversion and public reporting. Part 2: mitigation strategies. Ann Thorac Surg 2017;104:2102-10.
72. Green J, Wintfeld N. Report cards on cardiac surgeons. Assessing New York State’s approach. N Engl J Med 1995;332:1229-32.
73. Hannan EL, Kumar D, Racz M, Siu AL, Chassin MR. New York State’s Cardiac Surgery Reporting System: four years later. Ann Thorac Surg 1994;58:1852-7.
74. Hannan EL, Kilburn H Jr., Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA 1994;271:761-6.
75. Hannan EL, Siu AL, Kumar D, Kilburn H Jr., Chassin MR. The decline in coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume. JAMA 1995;273:209-13.
76. Shahian DM, Edwards FH, Ferraris VA, et al. Quality measurement in adult cardiac surgery: part 1––conceptual framework and measure selection. Ann Thorac Surg 2007;83:S3-12.
77. O’Brien SM, Shahian DM, DeLong ER, et al. Quality measurement in adult cardiac surgery: part 2––statistical considerations in composite measure scoring and provider rating. Ann Thorac Surg 2007;83:S13-26.
78. Rankin JS, Badhwar V, He X, et al. The Society of Thoracic Surgeons mitral valve repair/replacement plus coronary artery bypass grafting composite score: a report of The Society of Thoracic Surgeons Quality Measurement Task Force. Ann Thorac Surg 2017;103:1475-81.
79. Shahian DM, He X, Jacobs JP, et al. The Society of Thoracic Surgeons composite measure of individual surgeon performance for adult cardiac surgery: a report of The Society of Thoracic Surgeons Quality Measurement Task Force. Ann Thorac Surg 2015;100:1315-24. discussion 1324-5.
80. The Joint Commission. Comprehensive Cardiac Center Advanced Certification Program. Available at: https://www.jointcommission.or... approved_comprehensive_cardiac_center/. Accessed March 12, 2017.