Non-Imaging Responsibilities
9%of exam
Echocardiographic Imaging
24%of exam
Valvular Findings
25%of exam
Anatomy, Physiology + Hemodynamics
29%of exam
Ultrasound Physics
13%of exam
Quick Facts
- Credential
- CCI RCS
- Exam
- 170 total items
- Scored
- 150 items
- Unscored
- 20 unidentified items
- Appointment
- 3 hours
- Question time
- 2 hours 50 minutes
- Passing score
- 650/900 scaled
- Item types
- Traditional + innovative
- Delivery
- Pearson centers, year-round
- Exam fee
- $365
Workflow Memory
History, image, integrate, communicate
Verify firstOptimize nextEscalate significant findings
RCS vs RCCS
CCI RCS
- General echocardiography scope
- Current five-domain RCS JTA
- Congenital recognition included
CCI RCCS
- Separate CCI credential
- Pediatric/adult congenital focus
- Different qualification pathway
Recognition does not equal RCCS
Non-Imaging Workflow
- Clinical history
- Focus protocol
- Prior studies
- Compare serial change
- Echo order
- Verify request and scope
- Ergonomics
- Protect patient and staff
- Patient preparation
- Position, explain, instruct
- Findings report
- Support reading physician
- Significant finding
- Communicate promptly
- Infection control
- Use universal precautions
CCI RCS vs ARDMS RDCS
CCI RCS
- Issued by CCI
- CCI qualification pathways
- CCI renewal rules
ARDMS RDCS
- Issued by ARDMS
- Separate specialty examinations
- ARDMS renewal rules
Similar field, different credential
Doppler Memory
PW places; CW peaks; color maps
PW: rangeCW: velocityColor: direction
PW vs CW Doppler
PW
- Selects sample depth
- Aliases above Nyquist
- Maps obstruction level
CW
- Captures highest velocity
- No Nyquist aliasing
- Lacks range resolution
Location vs peak velocity
Doppler + Contrast Picker
- Need exact sample depth→PW Doppler(Range specific)
- Need highest jet velocity→CW Doppler(No range)
- Need flow direction map→Color Doppler
- Need annular tissue velocity→Tissue Doppler
- Need low-velocity flow→Lower color scale
- Need high-velocity flow→Raise color scale
- Need shunt screening→Agitated saline
- Need LV border enhancement→UEA contrast
Standard TTE Views
- PLAX
- LV, mitral, aortic anatomy
- PSAX base
- Great vessels and valves
- PSAX papillary
- LV wall motion
- Apical four-chamber
- Chambers, mitral, tricuspid
- Apical two-chamber
- Anterior and inferior walls
- Apical three-chamber
- LVOT and aortic valve
- Subcostal four-chamber
- Septum and pericardium
- IVC view
- Size and respiratory change
- Suprasternal view
- Aortic arch
Agitated Saline vs UEA
Agitated saline
- Opacifies right heart
- Screens abnormal passage
- Needs effective provocation
UEA
- Crosses pulmonary circulation
- Opacifies left ventricle
- Improves endocardial borders
Shunt screen vs LV enhancement
Imaging Modalities
- 2D TTE
- Anatomy and motion
- M-mode
- High temporal resolution
- Color Doppler
- Flow direction map
- PW Doppler
- Site-specific velocities
- CW Doppler
- Highest velocity, no range
- Tissue Doppler
- Myocardial velocities
- UEA contrast
- Improve endocardial borders
- Agitated saline
- Right-to-left shunt screening
- Exercise echo
- Physiologic stress imaging
- Pharmacologic echo
- Drug-induced stress imaging
- Nonischemic stress
- Hemodynamic provocation
- TEE assistance
- Esophageal imaging support
- Strain imaging
- Myocardial deformation
- 3D TTE/TEE
- Volumetric anatomy
Stenosis vs Regurgitation
Stenosis
- Restricted forward opening
- Velocity and gradient
- Valve area integration
Regurgitation
- Backward valve leakage
- Jet and flow measures
- Chamber response integration
Obstruction vs backward flow
Left-Sided Valves
- Aortic morphology
- Cusps, calcification, opening
- AS peak velocity
- Best-aligned CW envelope
- AS mean gradient
- Trace complete CW envelope
- Aortic valve area
- Continuity equation
- Dimensionless index
- LVOT VTI / AV VTI
- Aortic regurgitation
- Integrate jet, flow, remodeling
- Mitral morphology
- Leaflets, annulus, apparatus
- MS planimetry
- Leaflet-tip short-axis
- Mitral regurgitation
- Integrative severity assessment
- Vena contracta
- Narrowest jet neck
- PISA
- Quantitative regurgitant flow
- Pulmonary veins
- MR supportive flow pattern
Right-Sided Valves
- Tricuspid morphology
- Leaflets and coaptation
- Tricuspid stenosis
- Anatomy plus inflow
- Tricuspid regurgitation
- Jet plus right-heart response
- Hepatic veins
- TR supportive flow pattern
- Pulmonic morphology
- Valve and RVOT anatomy
- Pulmonic stenosis
- Localize obstruction level
- Pulmonic regurgitation
- Jet plus RV response
- Prosthetic valve
- Compare valve-specific baseline
- Endocarditis
- Mass, destruction, new regurgitation
Bernoulli Memory
Four times velocity squared
Delta P: mmHgV: m/sAlignment matters
Constriction vs Restriction
Constriction
- Pericardial process
- Respiratory septal shift
- Expiratory hepatic reversal
Restriction
- Myocardial process
- Stiff ventricular filling
- Biatrial enlargement
Pericardium vs myocardium
Evaluation Picker
- Suspected aortic stenosis→Multiwindow CW Doppler
- Suspected mitral regurgitation→Integrative valve assessment
- Suspected tamponade→Collapse plus respiratory Doppler
- Suspected pulmonary hypertension→Probability plus RV effects
- Suspected cardiac mass→Orthogonal views
- Suspected LV thrombus→Consider UEA
- Serial strain comparison→Match system and loading
- Implanted device→Trace route and effects
Chambers + Function
- LV volumes
- Nonforeshortened biplane apicals
- Ejection fraction
- Biplane disk summation
- Regional motion
- Thickening plus excursion
- LA volume
- Index to body size
- RV size
- RV-focused apical view
- TAPSE
- Longitudinal RV motion
- RV FAC
- Systolic area change
- Tricuspid S-prime
- RV tissue velocity
- Global strain
- Longitudinal deformation
- Serial strain
- Match system and physiology
Flow Memory
Area times VTI gives stroke volume
Area: diameter squaredVTI: distanceCO: SV x HR
Hemodynamics + Diastology
- Mitral E wave
- Early ventricular filling
- Mitral A wave
- Atrial contraction filling
- Mitral e-prime
- Myocardial relaxation
- E/e-prime
- Filling-pressure context
- TR velocity
- Pulmonary-pressure clue
- LA volume
- Chronic pressure burden
- Pulmonary veins
- Left-atrial filling pattern
- Hepatic veins
- Right-sided hemodynamic pattern
- RAP estimate
- IVC plus clinical context
- PASP estimate
- TR gradient plus RAP
Pathology Patterns
- HCM
- Hypertrophy, SAM, dynamic obstruction
- Dilated cardiomyopathy
- Dilation plus systolic dysfunction
- Restrictive physiology
- Stiff ventricles, enlarged atria
- Ischemia
- New regional motion abnormality
- Tamponade physiology
- Collapse plus respiratory variation
- Constrictive physiology
- Septal shift, hepatic reversal
- Aortic dissection
- Confirm flap in multiple planes
- Pulmonary hypertension
- Estimate probability and RV effects
- Cardiac mass
- Confirm in orthogonal views
- Congenital disease
- Recognize adult echo clues
- Implanted device
- Trace route and complications
- Infiltrative disease
- Integrate morphology and strain
Hemodynamic Equations
- Pressure gradient
- Delta P = 4V squared
- Circle area
- 0.785 x diameter squared
- Stroke volume
- Area x VTI
- Cardiac output
- SV x heart rate
- Ejection fraction
- EDV minus ESV / EDV
- Aortic valve area
- LVOT SV / AV VTI
- RVSP
- 4 x TRV squared + RAP
- Flow ratio
- Qp / Qs
Artifact vs Pathology
Artifact
- Changes with settings
- Violates expected anatomy
- May disappear orthogonally
Pathology
- Persists across views
- Respects anatomy
- Has physiologic support
Test before labeling
Image Optimization
- Image too dark→Increase gain carefully
- Far field too dark→Adjust TGC
- Poor penetration→Lower frequency
- Need finer detail→Raise frequency(Penetration cost)
- Motion looks choppy→Raise frame rate
- Frame rate too low→Reduce depth/sector/foci
- Suspected artifact→Change view/settings
- Foreshortened apex→Find true apical window
Wave + Resolution
- Soft-tissue speed
- 1540 m/s
- Wave equation
- c = frequency x wavelength
- Higher frequency
- Better detail, less penetration
- Axial resolution
- Half spatial pulse length
- Lateral resolution
- Beam width
- Temporal resolution
- Frame rate
- Focal zone
- Narrowest beam
- PRF
- Limited by depth
- Nyquist limit
- PRF / 2
- Doppler angle
- Parallel gives highest velocity
Artifacts
- Reverberation
- Repeated deeper echoes
- Mirror image
- Duplicated across reflector
- Acoustic shadow
- Signal loss behind reflector
- Enhancement
- Brighter behind weak attenuator
- Side lobe
- Off-axis echo misplaced
- Dropout
- Angle-dependent missing echoes
- PW aliasing
- Shift exceeds Nyquist
- Color blooming
- Excess gain paints tissue
- 3D stitching
- Beat-to-beat seam
Physics Optimization
- Overall gain
- All received echoes
- TGC
- Depth-specific amplification
- Depth
- Just beyond target
- Sector width
- Narrower raises frame rate
- Focal zones
- Fewer raises frame rate
- Color scale
- Match target velocity
- Wall filter
- Reject low-frequency clutter
- Spectral gain
- Reveal dense envelope
- Sweep speed
- Improve timing detail
- Contrast MI
- Limit routine bubble destruction
Common Traps
Scaled score
650 scaled points ≠ Not 65 percent
Unscored items
20 items unidentified ≠ Treat every item seriously
Color jet size
Eccentric jets may appear small ≠ Integrate multiple severity measures
Low-gradient stenosis
Gradient depends on flow ≠ Check valve area and flow
Pulmonary hypertension
Echo estimates probability ≠ Catheterization defines hemodynamics
Congenital scope
RCS recognizes congenital findings ≠ RCCS tests congenital specialty
Apparent mass
Confirm orthogonal views ≠ Exclude structures and artifacts
Precise wrong measurement
Alignment comes first ≠ Reacquire before tracing
Last Minute
- 1.Weights: 9 / 24 / 25 / 29 / 13
- 2.RCS is not RCCS
- 3.CCI RCS is not RDCS
- 4.170 total; 150 scored
- 5.650 scaled; not 65 percent
- 6.PW localizes; CW captures peak
- 7.Optimize before measuring
- 8.Use multiple acoustic windows
- 9.Integrate valve severity measures
- 10.Foreshortening distorts volumes and strain
- 11.Echo estimates PH probability
- 12.Communicate significant findings promptly
- 13.Delta P = 4V squared
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