Journal of the American College of Cardiology                                                                             ...
688        Quinones et al.              ˜                                                                                 ...
JACC Vol. 41, No. 4, 2003                                                                             Quinones et al.     ...
690         Quinones et al.               ˜                                                                               ...
JACC Vol. 41, No. 4, 2003                                                                                              Qui...
692         Quinones et al.               ˜                                                                               ...
JACC Vol. 41, No. 4, 2003                                                                             Quinones et al.     ...
694        Quinones et al.              ˜                                                                                 ...
JACC Vol. 41, No. 4, 2003                                                                                      Quinones et...
696      Quinones et al.            ˜                                                                                     ...
JACC Vol. 41, No. 4, 2003                                                                                         Quinones...
698         Quinones et al.               ˜                                                                               ...
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
ACC/AHA Clinical Competence Statement on Echocardiography
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ACC/AHA Clinical Competence Statement on Echocardiography

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ACC/AHA Clinical Competence Statement on Echocardiography

  1. 1. Journal of the American College of Cardiology Vol. 41, No. 4, 2003© 2003 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/03/$30.00Published by Elsevier Science Inc. doi:10.1016/S0735-1097(02)02885-1ACC/AHA CLINICAL COMPETENCE STATEMENTACC/AHA Clinical CompetenceStatement on EchocardiographyA Report of the American College of Cardiology/American HeartAssociation/American College of Physicians–American Society of Internal MedicineTask Force on Clinical CompetenceDeveloped in Collaboration with the American Society of Echocardiography,the Society of Cardiovascular Anesthesiologists, and the Society of Pediatric Echocardiography WRITING COMMITTEE MEMBERS ˜ MIGUEL A. QUINONES, MD, FACC, ChairPAMELA S. DOUGLAS, MD, FACC, FAHA ERNESTO E. SALCEDO, MD, FACCELYSE FOSTER, MD, FACC, FAHA JAMES B. SEWARD, MD, FACCJOHN GORCSAN, III, MD, FACC, FAHA J. GEOFFREY STEVENSON, MD, FACCJANNET F. LEWIS, MD, FACC, FAHA DANIEL M. THYS, MD, FACC, FAHAALAN S. PEARLMAN, MD, FACC, FAHA HOWARD H. WEITZ, MD, FACCJACK RYCHIK, MD, FACC WILLIAM A. ZOGHBI, MD, FACC, FAHA TASK FORCE MEMBERS MARK A. CREAGER, MD, FACC, Chair WILLIAM L. WINTERS, JR, MD, MACC, FAHA, Immediate Past Chair*MICHAEL ELNICKI, MD, FACC, FACP GEORGE P. RODGERS, MD, FACCJOHN W. HIRSHFELD, JR, MD, FACC, FAHA CYNTHIA M. TRACY, MD, FACC, FAHABEVERLY H. LORELL, MD, FACC, FAHA HOWARD H. WEITZ, MD, FACC, FACP TABLE OF CONTENTS A. Introduction ....................................................................689 Purpose of this Clinical Competence Statement ...........689Preamble....................................................................................688 Document Format ..........................................................689 B. General Principles...........................................................689 This document was approved by the American College of Cardiology Board of Basic Knowledge of Ultrasound Physics ........................690Trustees in December 2002 and the American Heart Association Science Advisory Technical Aspects of the Examination ..........................690and Coordinating Committee in November 2002. Anatomy and Physiology................................................690 When citing this document, the American College of Cardiology, the American Recognition of Simple and Complex Pathology............690Heart Association, and the American College of Physicians–American Society ofInternal Medicine would appreciate the following citation format: Quinones MA, ˜Douglas PS, Foster E, Gorcsan J, Lewis JF, Pearlman AS, Rychik J, Salcedo EE, C. Transthoracic Echocardiography in Adult Patients .......690Seward J, Stevenson JG, Thys DM, Weitz HH, and Zoghbi WA. ACC/AHA Overview and Indications for the Procedure .................690clinical competence statement on echocardiography: a report of the American College Minimum Knowledge Required for Performance andof Cardiology/American Heart Association/American College of Physicians– Interpretation ..................................................................690American Society of Internal Medicine Task Force on Clinical Competence (Com-mittee on Echocardiography). J Am Coll Cardiol 2003;41:687–708. Training Requirements ...................................................691 Address for Reprints: This document is available on the Web sites of the American Proof of Competence......................................................692College of Cardiology (www.acc.org), the American Heart Association (www. Board Examination.........................................................693americanheart.org), the American Society of Echocardiography (http://asecho.org), Certification ....................................................................693and the Society of Pediatric Echocardiography (www.sopeonline.com). Reprints ofthis document may be purchased for $5.00 each by calling 1-800-253-4636 or by Maintenance of Competence..........................................693writing to the American College of Cardiology, Resource Center, 9111 OldGeorgetown Road, Bethesda, Maryland 20814-1699. D. Transeophageal Echocardiography .................................693 *Former Task Force Chair during writing effort. Overview and Indications for the Procedure .................693
  2. 2. 688 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708 Minimum Knowledge Required for Performance and Minimum Knowledge Required for Performance Interpretation ..................................................................693 and Interpretation ....................................................707 Training Requirements ...................................................694 Training Requirements ............................................707 Proof of Competence......................................................695 Maintenance of Competence ...................................707 Maintenance of Competence..........................................695 References..................................................................................708 E. Perioperative Echocardiography .....................................696 Overview and Indications for the Procedure .................696 Minimum Knowledge Required for Performance and PREAMBLE Interpretation ..................................................................696 Training Requirements ...................................................696 The granting of clinical staff privileges to physicians is a Proof of Competence......................................................698 primary mechanism used by institutions to uphold the Maintenance of Competence..........................................699 quality of care. The Joint Commission on Accreditation of F. Stress Echocardiography.................................................699 Health Care Organizations requires that the granting of Overview and Indications for Procedure........................699 continuing medical staff privileges be based on assessments Minimum Knowledge Requirements for Performance of applicants against professional criteria specified in the and Interpretation ...........................................................699 medical staff bylaws. Physicians themselves are thus Training Requirements ...................................................699 charged with identifying the criteria that constitute Proof of Competence......................................................699 professional competence and with evaluating their peers Maintenance of Competence..........................................700 accordingly. Yet, the process of evaluating physicians’ knowledge and competence is often constrained by the G. Echocardiography for CHD Patients.............................700 evaluator’s own knowledge and ability to elicit the ap- Overview and Indications for Procedure........................700 Minimum Knowledge Required for Performance and propriate information, problems compounded by the Interpretation ..................................................................701 growing number of highly specialized procedures for Technical Aspects of the Examination ..........................701 which privileges are requested. Anatomy and Physiology................................................702 The American College of Cardiology/American Heart Recognition of Simple and Complex Pathology............702 Association/American College of Physicians–American So- Training Requirements ...................................................702 ciety of Internal Medicine (ACC/AHA/ACP–ASIM) Task Proof of Competence......................................................702 Force on Clinical Competence was formed in 1998 to Maintenance of Competence..........................................703 develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent H. Fetal Echocardiography ..................................................703 Overview and Indications for Procedure........................703 performance of a specific cardiovascular service, procedure, Minimum Knowledge Required for Performance and or technology. These documents are evidence-based, and Interpretation ..................................................................703 when evidence is not available, expert opinion is utilized to Training Requirements ...................................................704 formulate recommendations. Indications and contraindica- Proof of Competence......................................................705 tions for specific services or procedures are not included in Maintenance of Competence..........................................705 the scope of these documents. Recommendations are in- tended to assist those who must judge the competence of I. Emerging New Technologies .........................................705 cardiovascular health care providers entering practice for the 1. Hand-Carried Ultrasound Devices ..........................705 first time and/or those who are in practice and undergo Overview and Indications for the Procedure ...........705 Minimum Knowledge Required for Performance periodic review of their practice expertise. The assessment of and Interpretation ....................................................706 competence is complex and multidimensional; therefore, Training Requirements ............................................706 isolated recommendations contained herein may not neces- Proof of Competence ...............................................706 sarily be sufficient or appropriate for the judging of overall Maintenance of Competence ...................................706 competence. 2. Contrast Echocardiography......................................706 The ACC/AHA/ACP–ASIM Task Force makes every Overview and Indications for the Procedure ...........706 effort to avoid any actual or potential conflicts of interest Minimum Knowledge Required for Performance that might arise as a result of an outside relationship or and Interpretation ....................................................706 personal interest of a member of the ACC/AHA Writing Training Requirements ............................................706 Committee. Specifically, all members of the Writing Com- Proof and Maintenance of Competence..................706 mittee are asked to provide disclosure statements of all such 3. Intracoronary and Intracardiac Ultrasound..............706 Overview and Indications for the Procedure ...........706 relationships that might be perceived as real or potential Minimum Knowledge Required for Performance conflicts of interest. These changes are reviewed by the and Interpretation ....................................................707 Writing Committee and updated as changes occur. Training and Competence Requirements................707 Mark A. Creager, MD, FACC, 4. Echo-Directed Pericardiocentesis ............................707 Chair, ACC/AHA/ACP-ASIM Overview and Indications for the Procedure ...........707 Task Force on Clinical Competence
  3. 3. JACC Vol. 41, No. 4, 2003 Quinones et al. ˜ 689February 19, 2003:687–708 ACC/AHA Clinical Competence Statement on EchocardiographyA. Introduction Table 1. Echocardiographic ModalitiesThis document is a revision of the 1990 ACP/ACC/AHA ● Transthoracic two-dimensional/Doppler echocardiography ● Transesophageal echocardiographyClinical Competence in Adult Echocardiography (1). The ● Intra-operative echocardiographywriting committee consisted of recognized experts in echo- ● Stress echocardiographycardiography representing the ACC, AHA, ACP–ASIM, ● Miniaturized hand-carried ultrasoundAmerican Society of Echocardiography (ASE), Society of ● Contrast echocardiographyPediatric Echocardiography (SOPE), and the Society of ● Intracardiac and intravascular ultrasoundCardiovascular Anesthesiologists (SCA). The documenthas been approved for publication by the governing bodies cation of echocardiography in patients with complex CHD.of the ACC and the AHA, and endorsed by the ASE, SCA, The document also addresses the application of echocardi-and SOPE. ography using miniaturized hand-carried ultrasound instru-Purpose of this Clinical Competence Statement. Previ- ments. For each of the applications, there will be a briefous publications have focused on training requirements for general overview, a discussion of the cognitive skills requiredclinical competence in echocardiography. The first recom- and recommendations on training requirements, proof ofmendations were made in 1986 by Bethesda Conference 17: competence, and maintenance of competence. WheneverAdult Cardiology Training (2) and in 1987 by an expert possible, these recommendations will be linked to previouslypanel of the ASE (3). They were followed by a previous published recommendations made by specialty societies. Inversion of the ACP/ACC/AHA physician clinical compe- some situations, however, the writing group provides a set oftence statement in 1990. These earlier recommendations recommendation that represent the consensus of this bodywere limited primarily to the practice of transthoracic of experts.echocardiography (TTE) in the adult patient. However, This document makes an important distinction betweenover the past 15 years echocardiography has evolved into a training requirements and documentation of competence.family of techniques (Table 1), each one with unique Training requirements represent the minimal training ex-applications and its own set of cognitive skills and training perience that is considered necessary to achieve the skills forrequirements. Although the majority of these newer tech- performance at a particular level. It is recognized thatnologies were in their early phase of development in 1990, training is highly individualized and some trainees maytoday they are used routinely in community hospitals all require higher volume and more hours of exposure to aacross the nation. In addition, the application of echocar- particular technique. Proof of competence, on the otherdiography in children and adults with congenital heart hand, consists of a set of requirements that provide somedisease (CHD) has evolved into a highly specialized mo- assurance that physicians have gained the expertise neededdality with its own set of cognitive skills and training to perform according to recognized standards.requirements. Subspecialty societies such as the ASE have The sections on training requirements refer primarily topublished recommendations for training and, in some cases, the training needed to achieve specific levels of expertise.for competence in some of these newer techniques. In Such training is expected to occur under the direct super-addition, guidelines for training in adult cardiovascular vision of a qualified Level 3 or equivalent physician/teachermedicine in the form of a suggested core curriculum and for the most part, occurs during formal fellowship(COCATS) have included recommendations on training in training in either cardiovascular medicine or cardiovascularechocardiography, first in 1995 and currently in a revised anesthesiology. However, the document recognizes the factversion (4). The recently formed National Board of Echo- that physicians trained prior to the development of thesecardiography (NBE) has also introduced guidelines for certi- techniques may have properly learned their use while infication of special competence in adult echocardiography, practice. Thus, whenever possible, the document addresseswhich includes passing an examination in addition to specific training requirements and proof of competence for thistraining requirements. Separate certifications are granted for group of physicians. Maintenance of competence requirestransesophageal echocardiography (TEE) and stress echocar- the performance of a certain minimal volume of proceduresdiography. Recognizing the growths in technology and the and participation in continuing medical education (CME).increased complexity of echocardiography, the members of the This document recommends that physicians practicingACC/AHA/ACP–ASIM Task Force on Clinical Compe- echocardiography obtain a minimum of 5 hours per year oftence commissioned this writing group to provide a new set of CME credits in echocardiography, as recommended re-recommendations that recognize the different cognitive skills cently by the Intersocietal Commission for the Accredita-required for each of the new modalities and that address tion of Echocardiography Laboratories (ICAEL Newslettertraining, documentation and maintenance of competence. 2001Vol 4; Issue 2; page 5).Document Format. This document addresses competence B. General Principlesin the performance and interpretation all the differentmodalities of echocardiography, including new applications Regardless of the echocardiographic modality utilized, thereof echocardiography in the operating room and the appli- is a body of knowledge required by any physician involved in
  4. 4. 690 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708Table 2. Basic Cognitive Skills Required for Competence quantify blood flow velocities and calculate blood flow;in Echocardiography assess intracardiac pressures and hemodynamics; and detect● Knowledge of physical principles of echocardiographic image and quantify stenosis, regurgitation, and other abnormal formation and blood flow velocity measurements. flow states. Documentation of normal and abnormal cardiac● Knowledge of instrument settings required to obtain an optimal anatomy and physiology must be accomplished by the image. individual performing the examination.● Knowledge of normal cardiac anatomy.● Knowledge of pathologic changes in cardiac anatomy due to acquired Recognition of Simple and Complex Pathology. The and CHD. ability to recognize both simple and complex pathology of● Knowledge of fluid dynamics of normal blood flow. the heart and great vessels is required for competence in● Knowledge of pathological changes in blood flow due to acquired echocardiography. A fundamental knowledge of cardiac heart disease and CHD. pathology is required during data acquisition to tailor theCHD congenital heart disease. examination appropriately and maximize demonstration of the abnormalities present. This includes the ability toperformance and/or interpretation of echocardiograms that modify standard imaging planes and optimize the Dopplerincludes: ultrasound physics and use of instrumentation, beam angle of incidence to achieve this goal. In addition, ananatomy, physiology, and pathology of the heart and great extensive knowledge of pathology and pathophysiology isvessels (Table 2). required to interpret recorded echocardiographic data.Basic Knowledge of Ultrasound Physics. Echocardio-graphic imaging and Doppler systems generate ultrasound C. Transthoracic Echocardiography in Adult Patientssignals that follow the laws of physics. Appropriate utiliza- Overview and Indications for the Procedure. Transtho-tion of these instruments and interpretation of the data racic two-dimensional and Doppler echocardiography is onegenerated require an understanding of the fundamental of the most important and frequently performed diagnosticprinciples of ultrasound physics and how they relate to the procedures for patients with cardiovascular disease. It pro-images produced and the spectral and color Doppler infor- vides highly accurate diagnostic information regarding themation. This understanding is considered to be an impor- anatomy and physiology of the cardiac chambers, valves,tant requirement for clinical competence in all modalities of major vessels, and pericardium in a noninvasive and instan-echocardiography. taneous manner. This information can immediately affectTechnical Aspects of the Examination. An essential com- the further diagnostic work-up for the patient, dictateponent of the diagnostic accuracy of echocardiography is the therapeutic decisions, determine response to therapy, andskill and experience of the individual responsible for image predict patient outcome. Because transthoracic two-and data acquisition. Technical skills related to echocardio- dimensional/Doppler echocardiography plays such a majorgraphic data acquisition may be divided into two important role in the care of patients with suspected or knownskill sets: transducer manipulation and ultrasound system cardiovascular diseases, the widely accepted indications foradjustments. Perhaps the most difficult and underestimated the procedure span the breadth of cardiovascular medicine,skill set to master is transducer manipulation, which is including but not limited to the diagnosis of and guidingcritical to obtaining optimal image quality in standard treatment for: coronary artery disease, valvular heart disease,tomographic imaging planes, and optimal Doppler flow heart failure, hypertensive heart disease, congenital abnor-velocity signals. This is true regardless of the type of malities, complications of pulmonary disease, tumors/transducer utilized (i.e., transthoracic, transesophageal, or masses, cardiac trauma, pericardial disease, and others.intravascular). The second set of technical skills includes Details of accepted indications have been recently revisedappropriate knowledge of ultrasound instrument settings (ACC/AHA Guidelines revision, publication pending).such as transducer frequency, use of harmonics, mechanical This section will discuss the cognitive requirements, train-index, depth, gain, time-gain-compensation, dynamic ing, proof of competence, and maintenance of competencerange, filtering, velocity scale manipulations, and display of for performance and/or interpretation of TTE in adultreceived signals. patients with acquired diseases and/or simple congenitalAnatomy and Physiology. Echocardiography is a powerful heart defects. A separate section is dedicated to the use ofdiagnostic tool that provides immediate access for the echocardiography in pediatric patients and adults withevaluation of cardiac and vascular structures and assessment complex congenital defects, as defined by the Task Force 1of heart function. Intrinsic to a competent echocardio- Report from the 32nd Bethesda Conference on “Care of thegraphic examination is a thorough understanding of the Adult with Congenital Heart Disease” (5). Simple lesionsanatomy and physiology of the heart and great vessels. are listed in Table 3.Two-dimensional imaging can accurately quantify cardiac Minimum Knowledge Required for Performance andchamber sizes, wall thickness, ventricular function, valvular Interpretation (Table 4). Competence in performinganatomy, and great vessel size. Pulsed, continuous-wave, and/or interpreting TTE in adult patients requires all of theand color-flow Doppler echocardiography, especially when basic knowledge of ultrasound physics, of instrumentation,combined with two-dimensional imaging, can be used to and of cardiac anatomy, physiology and pathology described
  5. 5. JACC Vol. 41, No. 4, 2003 Quinones et al. ˜ 691February 19, 2003:687–708 ACC/AHA Clinical Competence Statement on EchocardiographyTable 3. Classification of Simple Congenital Lesions Table 5. Training Requirements for Performance and Interpretation of Adult Transthoracic Echocardiography1. Valvular/Vascular Isolated congenital aortic valve disease Minimum Total Isolated sub-aortic membrane Cumulative Number of Minimum Number Isolated congenital mitral valve disease (except parachute valve, cleft Duration Examinations of Examinations valve) of Training Performed Interpreted Isolated valvular pulmonic stenosis Level 1 3 months 75 150 Uncomplicated Ebstein’s anomaly Level 2 6 months 150 (75 additional) 300 (150 additional) Simple coarctation of the aorta Level 3 12 months 300 (150 additional) 750 (450 additional) Sinus of valsalva aneurysm Persistent left superior vena cava2. Shunts Training Requirements (Table 5). Training in adult TTE Isolated atrial septal defects or patent foramen ovale Isolated small ventricular septal defects remains intimately linked to training in other aspects of Isolated patent ductus arteriosus adult cardiovascular medicine, including cardiovascular catheterization, inpatient and outpatient clinical care, elec-in the section on General Principles. Transducer manipu- trocardiography, pacing and electrophysiology, cardiac sur-lation is perhaps the most difficult and underestimated skill gery, and other noninvasive imaging. The number of pro-set to master when performing a transthoracic echocardio- cedures required to accomplish clinical competence in two-graphic examination. It is the most important factor in dimensional Doppler echocardiography is, in reality,obtaining optimal image quality in standard tomographic somewhat arbitrary because there is individual variation inimaging planes and optimal Doppler flow velocity signals. cognitive, analytical, and manual-dexterity skills. Further-As previously mentioned, appropriate knowledge of ultra- more, the breadth of the clinical experience is equally assound instrument settings such as depth, gain, time-gain- important as the numbers themselves, in that supplementalcompensation, dynamic range, filtering and display of re- training may be required in centers where patient popula-ceived signals is essential for performing an optimal tions are skewed by specific referral patterns. It is importantexamination. Even though the majority of echocardio- to emphasize that the numbers of examinations refer tographic examinations are performed by sonographers and comprehensive two-dimensional and Doppler echocardio-interpreted by physicians in most clinical settings in the graphic studies that are diagnostic, complete, and quantita-United States, all physicians interpreting scans are required tively accurate.to be skilled in echocardiographic data acquisition as well. The numbers set forth in this document reflect theThis facilitates the physician’s understanding of optimal minimum requirements for the average trainee engaged in aechocardiographic data acquisition and technical quality. training program in adult cardiovascular medicine. ThesePhysicians who are ultimately responsible for the diagnostic numbers have been revised specifically to reflect the realitydata should play an appropriate role in quality control and of mainstream training programs in cardiovascular medicineteaching in the sonographer-physician relationship. The in the current era. A new distinction has been made betweenechocardiographic physician should accordingly be available the performance of echocardiograms and interpretation offor consultation with the sonographer. Furthermore, a echocardiograms. Expert consensus remains that all physi-physician properly trained in echocardiographic data acqui- cians involved in the practice of the subspecialty of cardio-sition should be able to perform emergency bedside echo- vascular medicine or who participate in interpreting echo-cardiographic examinations when a sonographer is not cardiograms must be trained at a minimum level inavailable. performing echocardiograms (Table 5). Level 1 Training (3 months, 75 examinations performed,Table 4. Cognitive Skills Required for Competence in Adult 150 examinations interpreted). Level 1 is defined as theTransthoracic Echocardiography minimal introductory training that must be achieved by all● Basic knowledge outlined in Table 2. trainees in adult cardiovascular medicine. This includes a● Knowledge of appropriate indications for echocardiography. basic understanding of the physics of ultrasound, the fun-● Knowledge of the differential diagnostic problem in each case and the echocardiographic techniques required to investigate these possibilities. damental technical aspects of the examination, cardiovascu-● Knowledge of appropriate transducer manipulation. lar anatomy and physiology as it relates to echo and Doppler● Knowledge of cardiac auscultation and electrocardiography for imaging, and recognition of simple as well as complex correlation with results of the echocardiogram. cardiac pathology and pathophysiology. Level 1 trainees are● Ability to distinguish an adequate from an inadequate required to train in echocardiography for a minimum of echocardiographic examination.● Knowledge of appropriate semi-quantitative and quantitative three months and perform and interpret a minimum of 75 measurement techniques and ability to distinguish adequate from two-dimensional and Doppler TTEs, and interpret an inadequate quantitation. additional 75 two-dimensional and Doppler TTEs (total of● Ability to communicate results of the examination to the patient, 150 exams interpreted). This nominal hands-on training medical record, and other physicians. should enable a physician to expand on or clarify the data● Knowledge of alternatives to echocardiography. acquired by a sonographer, and to understand potential
  6. 6. 692 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708Table 6. Documentation and Maintenance of Competence in Transthoracic Echocardiography Training Guidelines Proof of CompetenceDocumentation of Competence Training completed after July 1, 1998 1) Level 2 training 1) Letter or certificate from training supervisor,* or 2) NBE certification Training completed between 1) Level 2 training or 1) Letter or certificate from training supervisor* or July 1, 1990, and July 1, 1998 2) 3 months training, 150 studies performed and 2) NBE certification or interpreted, and 400 studies per year for 2 3) ICAEL accreditation years Training completed prior to 1) Level 2 training or 1) Letter or certificate from training supervisor* or July 1, 1990 2) 400 studies per year for 3 years 2) NBE certification or 3) ICAEL accreditation or 4) Letter attesting to competence from Level 3 trained physician who has over read 25 studiesMaintenance of Competence Level 2 Performance and/or interpretation of 300 studies per year Level 3 Performance and/or interpretation of 500 studies per year†All numbers represent minimum requirements. *Training program director, echocardiography laboratory director, or equivalent. †Periodic performance of echocardiographicstudies is highly recommended. ICAEL Intersocietal Commission for the Accreditation of Echocardiography Laboratories; NBE National Board of Echocardiography.technical limitations and artifacts. Level 1 training is not July 1990 (when the Level 1 to 3 guidelines were adopted)sufficient for a trainee to perform or interpret echocardio- are considered clinically competent for independent perfor-grams independently. mance and interpretation if they have either the equivalent Level 2 Training (6 months, 150 examinations performed of Level 2 training, as previously set forth, or have the[75 additional] and 300 interpreted [150 additional]. Level experience of providing echocardiographic services for a2 training is the minimum recommended training for a minimum of 400 examinations performed and/or inter-physician to perform and interpret echocardiograms inde- preted per year for a minimum of 3 years. Physicians whopendently. These requirements are specifically for transtho- completed training in Cardiovascular Disease between Julyracic two-dimensional and Doppler echocardiography. 1990 and July 1998 are considered clinically competent inLevel 2 is defined as a minimum of an additional 3 months echocardiography with the equivalent of Level 2 training, asof training in echocardiography (6 months cumulative) and previously set forth, if they completed 3 months training inthe addition of 150 transthoracic two-dimensional and echocardiography with performance and interpretation ofDoppler examinations interpreted (300 cumulative exams 150 transthoracic echocardiograms, and have providedinterpreted). Additional training in special procedures, such echocardiographic services of a minimum of 400 echo andas TEE and stress echocardiography, is detailed subse- Doppler examinations per year for a minimum of 2 years.quently in this document. Although some experience in Physicians who completed training in Cardiovascular Dis-special procedures may be attained as a part of Level 2 ease after July 1998 can be considered clinically competenttraining, in most instances, full competence in these areas in echocardiography with 6 months of training, a minimumwill require additional training beyond Level 2. of 150 examinations performed and a total of 300 exami- Level 3 Training (12 months, 300 transthoracic two- nations interpreted.dimensional and Doppler echocardiograms performed [150 Proof of Competence (Table 6). The optimal evaluationadditional] and 750 interpreted [450 additional]). Level 3 of clinical competence is performed by an individual orrepresents a high level of expertise that would enable an individuals who observe the trainee directly. This is usuallyindividual to serve as a director of an echocardiography accomplished by the director of the echocardiography lab-laboratory and be directly responsible for quality control and oratory or by qualified faculty who participate in the trainingfor the training of sonographers and physicians in echocar- activities of the laboratory. Trainees are strongly encourageddiography. Although these guidelines reflect the minimum to maintain a log with counts of all performed and inter-number of TTE and Doppler studies, most physicians who preted echocardiograms that should be updated regularly. Aare Level 3-trained will also have additional training in letter or certificate from either the supervising echocardiog-TEE and stress echocardiography. It should be emphasized raphy laboratory director or the training program director,that these numbers reflect the minimum examinations with input from the echocardiography laboratory director,considered for clinical competence; many training programs should document both the duration of training and thewill offer a greater experience in interpretation of transtho- counts of performed and interpreted echocardiograms at theracic echocardiograms over the time periods previously end of their training program (Table 6).outlined. In addition to the training requirements outlined in the Physicians who trained in Cardiovascular Disease before foregoing text, proof of competence for individuals trained
  7. 7. JACC Vol. 41, No. 4, 2003 Quinones et al. ˜ 693February 19, 2003:687–708 ACC/AHA Clinical Competence Statement on Echocardiographybefore 1990 may be established in one of the following three for examining the heart and great vessels. Its clinicalways: 1) NBE Board Certification; 2) active participation by applications include, but are not limited to: detection andthe physician in a laboratory accredited by the Intersocietal assessment of endocarditis and its complications, aorticCommission for the Accreditation of Echocardiography dissection and other aortic pathologies, intracardiac thrombiLaboratories (ICAEL), with demonstration that the physi- and other masses, evaluation of valvular disorders includingcian interprets a minimum of 300 studies per year, or 3) prosthetic valve function, and evaluation of a variety ofEndorsement by a Level 3-trained physician who has CHDs in both children and adults. Transesophageal echo-overread a minimum of 25 examinations interpreted by the cardiography is also of great use in patients with suspectedindividual. This Level 3-trained echocardiography physician cardiac trauma, in critically ill medical or surgical patientsmay be either on-site or off-site in circumstances where a with unstable hemodynamics, and in patients whose clinicalLevel 3-trained physician is not available on-site. status necessitates echocardiographic assessment but inBoard Examination. The NBE was formed in December whom TTE studies are technically inadequate or non-of 1998 to establish criteria for Special Competence in diagnostic. In many large echocardiography laboratories,Adult Echocardiography. These requirements include the TEE studies represent between 5% and 10% of the totalsuccessful completion of a written board examination for volume of echocardiographic examinations.Special Competence in Adult Echocardiography, known as Transesophageal echocardiography is a minimally inva-the ASCeXAM, and the completion training requirements sive procedure with small but definite risks (7). Therefore, itconsistent with this statement and the COCATS docu- should be reserved for clinical circumstances in which thement. potential findings have significant implications for patientCertification. The NBE has established a process to issu- management and cannot be obtained by transthoracic eval-ing certification for Special Competence in Adult Echocar- uation.diography, specifically in transthoracic two-dimensional and Minimum Knowledge Required for Performance andDoppler echocardiography, to physicians who have success- Interpretation (Table 7). Competence in performing andfully completed all training requirements and have passed interpreting TEE in adult patients requires all of the basicthe ASCeXAM. Specific details regarding certification are knowledge of ultrasound physics and instrumentation asoffered on the NBE web site: www.echoboards.org. well as the cardiac anatomy, physiology, and pathologyMaintenance of Competence (Table 6). Clinical compe- described in the section on General Principles. The specifictence in echocardiography requires continued maintenance cognitive and technical skills needed to perform TEE in aof skills in two-dimensional and Doppler echocardiography. competent manner are listed in Table 7 (8).Upon completion of the training requirements as previously Transesophageal echocardiography requires the insertiondiscussed, a minimum of performance and/or interpreta- of an endoscopic probe into the esophagus and manipulat-tions of 300 examinations per year are required to remain ing the probe through multiple imaging planes to obtainproficient in providing echocardiographic services at Level tomographic views of the heart and great vessels. To reduce2. Because Level 3 skills include the supervision and the level of discomfort associated with the procedure, aeducation of sonographers and physicians training in echo- topical anesthetic spray is administered to the oropharynx,cardiography, maintenance of these skills requires physi- and intravenous conscious sedation is often used. Conse-cians to perform and/or interpret a minimum of 500 quently, the physician performing a TEE must be knowl-transthoracic echocardiograms annually. In addition, it is edgeable with regard to: pharyngeal and esophageal anat-essential that Level 3 physicians maintain their skills by omy; the proper use of conscious sedation, including theperforming transthoracic examinations. This can be done by prompt recognition of possible complications; the variousperiodically assisting the sonographers with the perfor- techniques of esophageal intubation and probe manipula-mance of more complex cases. Continuing medical educa- tion; the recognition and management of possible compli-tion in echocardiography is essential to keep pace with cations of probe insertion, including the infrequent occur-ongoing technical advances, refinements in established tech- rence of methemoglobinemia as a complication ofniques, and applications of new methods. Although mini- benzocaine administration; and the absolute and relativemal guidelines for CME are outlined in Section A, it is contraindications to the performance of a TEE examina-recommended that Level 3 physicians exceed these minimal tion. The operator must also have the necessary technicalstandards so that they can remain as true experts in knowledge required to operate the ultrasound machine.echocardiography. A program for continuous quality im- Importantly, the physician performing a TEE needs goodprovement in echocardiography should be employed as communication skills in order to explain the TEE procedureoutlined in the ASE Continuous Quality Improvement to patients in simple terms, including its risks, benefits, anddocument (6). alternative approaches—and in order to obtain the patient’s cooperation during the examination. In many patients, theD. Transesophageal Echocardiography results of a TEE examination guide urgent and definitiveOverview and Indications for the Procedure. Trans- treatment (such as emergency surgery in a patient with anesophageal echocardiography provides an excellent window ascending aortic dissection); thus, the physician performing
  8. 8. 694 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708Table 7. Cognitive and Technical Skills Required for principles of ultrasound imaging and Doppler hemody-Competence in TEE namic assessment described in detail in the previous sec-Cognitive Skills tions.● Basic knowledge outlined in Tables 2 and 4. Although it is usually preferable to perform a compre-● Knowledge of the appropriate indications, contraindications, and risks hensive and systematic TEE examination, it is not always of TEE.● Understanding of the differential diagnostic considerations in each possible, particularly in critically ill patients. Consequently, clinical case. it is essential that the operator evaluate the most pressing● Knowledge of infection control measures and electrical safety issues diagnostic issues first. Therefore, the physician performing a related to the use of TEE. TEE must be able to review available clinical and diagnostic● Understanding of conscious sedation, including the actions, side effects information, including data from the TTE, in order to and risks of sedative drugs, and cardiorespiratory monitoring.● Knowledge of normal cardiovascular anatomy, as visualized prioritize the most relevant issues and focus the TEE tomographically by TEE. examination on resolving these issues.● Knowledge of alterations in cardiovascular anatomy that result from Training Requirements (Table 8). The proper perfor- acquired and congenital heart diseases and of their appearance on mance and interpretation of the TEE examination requires TEE. training in a number of elements such as: appropriate use of● Understanding of component techniques for transthoracic echocardiography and for TEE, including when to use these methods sedatives, proper and safe introduction of the TEE probe, to investigate specific clinical questions. manipulation of the TEE transducer, optimization of the● Ability to distinguish adequate from inadequate echocardiographic echocardiographic instrument, correct interpretation of the data, and to distinguish an adequate from an inadequate TEE study findings, and communication of findings to other examination. healthcare providers in an articulate and effective manner.● Knowledge of other cardiovascular diagnostic methods for correlation with TEE findings. This training is best obtained during a formal fellowship in● Ability to communicate examination results to the patient, other cardiovascular medicine, or its equivalent, and through health care professionals, and medical record. active participation in a training program in general TTE. Alternatively, the training can be achieved as part of aTechnical Skills● Proficiency in using conscious sedation safely and effectively. cardiovascular anesthesiology or critical care medicine fel-● Proficiency in performing a complete transthoracic echocardiographic lowship, with a formal period of intensive education in an examination, using all echocardiographic modalities relevant to the affiliated diagnostic echocardiography laboratory. case. Specifically, trainees must perform esophageal intuba-● Proficiency in safely passing the TEE transducer into the esophagus tions (using a diagnostic TEE probe) under the tutelage of and stomach, and in adjusting probe position to obtain the necessary tomographic images and Doppler data. an experienced physician with advanced skills in TEE or● Proficiency in operating correctly the ultrasonographic instrument, under the supervision of an experienced endoscopist. Train- including all controls affecting the quality of the data displayed. ees must also perform a number of TEE examinations under● Proficiency in recognizing abnormalities of cardiac structure and the tutelage of an experienced TEE operator before per- function as detected from the transesophageal and transgastric forming TEE examinations independently. It is crucial that windows, in distinguishing normal from abnormal findings, and in recognizing artifacts. trainees learn to recognize normal and abnormal findings● Proficiency in performing qualitative and quantitative analyses of the “on-line” and to manipulate the probe to obtain optimal echocardiographic data. views for evaluating the abnormalities observed. Because the● Proficiency in producing a cogent written report of the results of a TEE examination are frequently considered echocardiographic findings and their clinical implications. “definitive” and used to make immediate and importantAdapted from Pearlman et al. (8). management decisions, we do not believe in defining TEE transesophageal echocardiography. different levels of competence. Therefore, in regard to TEE,a TEE needs to have a thorough knowledge of cardiovas- “minimum training” and “optimal training” are the same.cular disorders and their accompanying hemodynamic alter- We endorse the previously published recommendations ofations, the different diagnostic issues that require consider- the ASE (8) and the ACC (4).ation given a particular clinical presentation, and the For physicians in formal cardiology fellowship trainingpotential therapies available. The operator also needs to programs, training in TEE should include 1) attainment ofhave mastered a thorough understanding of the basic at least Level 2 experience in general TTE; 2) performance Table 8. Training Requirements for Performance and Interpretation of TEE Approximate Component Objective Caseload General transthoracic echo, Level 2 Background knowledge and skills 300 interpreted 150 performed Esophageal intubation TEE probe introduction 25 TEE examinations Skills in performance and interpretation 50 Abbreviations same as Table 7.
  9. 9. JACC Vol. 41, No. 4, 2003 Quinones et al. ˜ 695February 19, 2003:687–708 ACC/AHA Clinical Competence Statement on Echocardiography Table 9. Documentation and Maintenance of Competence in TEE Completion of Training Documentation Needed Before July 1, 1998 Training in cardiovascular diseases ABIM certification or certificate of successful completion of training, or letter from training program director. Training in TTE Documentation of Level 2 training in TTE (see section C). Training in TEE Documentation of performance and interpretation of 50 supervised TEE cases, via letter or certificate from training supervisor*, or notarized letter documenting performance and interpretation of at least 50 TEE studies per year for the previous 2 years, or NBE certification in TEE. After July 1, 1998 Training in cardiovascular diseases ABIM certification or certificate of successful completion of training, or letter from training program director. Training in TTE Documentation of Level 2 training in TTE (see section C–Table 6). Training in TEE Letter or certificate from training supervisor* documenting performance and interpretation of 50 supervised TEE cases, or NBE certification in TEE. Maintenance of competence Performance of 25–50 TEE examinations per year. *Training program director, echocardiography laboratory director, or equivalent. ABIM American Board of Internal Medicine; NBE National Board of Echocardiography; TEE transesophogeal echo; TTE transthoracic echo.of approximately 25 esophageal intubations with a TEE transthoracic, TEE, stress echocardiography, or compre-probe; and 3) performance of approximately 50 diagnostic hensive certification).TEE examinations under the supervision of an experienced Maintenance of Competence (Table 9). Maintenance of(Level 3) echocardiographer, including the review, interpre- competence in TEE requires both ongoing continuingtation, and reporting of study findings. It is important to education and regular performance of TEE examinations.emphasize that in certain specialized clinical circumstances, Physicians performing TEE examinations should periodi-even this training may not be sufficient for the independent cally attend postgraduate courses and workshops that focusperformance of a TEE. For example, assessment of complex on clinical applications of TEE, especially those that em-congenital heart lesions, and intraoperative evaluation of the phasize new and evolving techniques and developments. Insuitability for and results of surgical repair of valvular addition, physicians should seek to compare the quality,regurgitation, are particularly demanding and require addi- completeness, and results of their own examinations withtional training and expertise. those presented at scientific meetings and in professional Physicians who are not enrolled in a cardiology publications. On-line or other multimedia formats givefellowship-training program need to acquire similar knowl- physicians increasing access to a variety of materials that canedge and to develop similar skills. This could be accom- help them keep up with the field.plished through an intensive period of training in an active Ongoing performance of diagnostic TEE examinations isTEE training program or through ongoing training under needed to maintain technical skills and to keep up withthe guidance and supervision of an experienced (Level 3) developments in the field. Infrequent performance of TEEechocardiographer with significant expertise in TEE. increases the risk of complications or of inaccurate resultsProof of Competence (Table 9). Documentation of com- and inappropriate patient treatment. The guidelines onpetence can be achieved by means of a letter or certificate training in TEE published by the ASE in 1992 recom-from the director of the echocardiography laboratory in mended performing 50 to 75 TEE examinations per yearwhich the trainee obtained TEE training or from the (8). Given the greater exposure to training in this modalitytraining program director, with input from the echocardi- over the past 10 years and recognizing that achieving such aography laboratory director. This documentation should volume may be difficult in routine clinical practice, thisstate that the trainee successfully achieved or surpassed each writing group recommends that a minimum of 25 to 50of the training elements, and the dates of training. For cases per year be required to maintain adequate cognitivephysicians whose training in echocardiography was com- and technical skills in performing and interpreting TEE. Ofpleted before July 1, 1998, a Level 2 equivalence in TTE course, TEE examinations should not be performed simplyshould be documented, as detailed in the previous section. to meet these guidelines, but they must be indicated onIn addition they must document performance of a minimum clinical grounds and appropriate to good patient care.of 50 TEE cases per year, for the preceding two years. We Physicians at the lower end of the recommended numberbelieve that ideally, physicians should take the board exam- should work in association with a laboratory where a greaterination offered by the NBE, and achieve certification in the volume is performed, so that they can be exposed to anrelevant practice areas of echocardiography (i.e., general adequate variety of pathology. On the other hand, physi-
  10. 10. 696 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708cians who cannot meet the recommended number should indications that lie within the customary practice of anes-perform the procedure in conjunction with more experi- thesiology, such as the perioperative diagnosis of myocardialenced operators. Continuing medical education in echocar- ischemia and infarction, the perioperative assessment ofdiography and TEE is essential to keep pace with ongoing hemodynamics and ventricular function, and the perioper-technical advances, refinements in established techniques, ative diagnosis and management of cardiovascular collapse;and applications of new methods. Minimal CME require- and 2) indications that guide surgical decisions in thements are outlined in Section A. operating room. In this regard, cardiovascular lesions are We also subscribe to the principles of Continuing Quality diagnosed, and the information is used to influence theImprovement in Echocardiography (6), and recommend patient’s surgical management. The results of surgical inter-that a random sample of TEE studies performed by an ventions may be assessed by echocardiography, and theindividual operator periodically be reviewed by a qualified findings may guide additional surgical therapy, if necessary.expert (from the operator’s own institution or, if necessary, A physician should perform the perioperative echocardio-from the outside), as part of a quality assessment program. graphic examination. Although a sonographer may assistThis review should be performed in an educational and the physician, the physician must always be present tonon-punitive manner and should help to determine if TEE interpret the echocardiographic data and assist the surgeonstudies had been performed for appropriate indications, if in planning the surgical procedure.studies were of sufficient completeness and technical quality Minimum Knowledge Required for Performance andto resolve the relevant diagnostic questions, if findings were Interpretation (Table 10). Competence in performing andinterpreted and reported correctly, and if results were interpreting perioperative echocardiography in adult pa-reported in an effective and timely manner. Recurring tients requires basic knowledge of ultrasound physics, in-variations from the norm would then serve to highlight strumentation, and cardiac anatomy, physiology, and pa-areas for further quality improvement and thereby help thology outlined in the section on General Principles.facilitate better patient care. Continuing Quality Improve- Although several guidelines describe the knowledge neces-ment considerations also mandate that the results of TEE sary to perform echocardiography, few have focused on theexaminations be compared, whenever possible, with the specific knowledge and skills necessary for the practice offindings from cardiac catheterization or other cardiac imag- perioperative echocardiography. Specific guidelines oning studies, cardiac surgery, or necropsy in order to establish training in perioperative TEE have been recently publishedand maintain diagnostic accuracy. by an ASA/SCA Task Force (11). These recommendations which were developed mainly for anesthesiologists, recog-E. Perioperative Echocardiography nized that perioperative echocardiography was practiced atOverview and Indications for the Procedure. Periopera- different levels. Some anesthesiologists predominantly usetive echocardiography refers to the application of echocar- echocardiography for monitoring purposes in the detectiondiographic examination techniques in patients undergoing of myocardial ischemia or the evaluation of intracardiacsurgical procedures (intraoperative echocardiography) and hemodynamics and ventricular function (basic level), whileduring the early postoperative period. Early echocardio- others use the full diagnostic potential of echocardiographygraphic examinations used epicardial echocardiographic in the perioperative period (advanced level). The knowledgeprobes that had limited clinical applicability. Today, the and skills necessary to practice perioperative echocardiogra-examination is performed predominantly through the trans- phy at the basic and advanced levels are summarized inesophageal approach, although epicardial and epivascular Tables 10 and 11, respectively. For non-anesthesiologiststechniques continue to play a role during surgery, particu- who practice perioperative echocardiography, any necessarylarly in the echocardiographic assessment of the thoracic knowledge beyond what is listed in the tables relates toaorta. physiologic changes induced by anesthetic agents, mechan- Perioperative echocardiography utilizes most of the echo- ical ventilation, and cardiopulmonary bypass.cardiographic modalities used in the non-operative setting. Training Requirements (Table 12). We endorse theThey include M-mode and two-dimensional imaging tech- recent ASA/SCA task force recommendation of two levelsniques as well as pulsed, continuous-wave and color flow of training for perioperative echocardiography, basic andDoppler. Most modern transesophageal probes have multi- advanced (10,11). Both basic and advanced TEE trainingplane capabilities. The ASE and the Society of Cardiovas- refer to specialized TEE training that extends beyond thecular Anesthesiologists (SCA) have published guidelines for minimum exposure to echocardiography that occurs duringthe performance of a comprehensive perioperative multi- normal anesthesia residency training. Anesthesiologists withplane transesophageal examination (9). basic training are considered able to use TEE for indications The indications for perioperative echocardiography have that lie within the customary practice of anesthesiology.been summarized by a task force of the American Society of Anesthesiologists with advanced training are, in addition,Anesthesiologists/Society of Cardiovascular Anesthesiolo- able to utilize the full diagnostic potential of perioperativegists (ASA/SCA) and published as practice guidelines in TEE.1996 (10). They can be divided into two broad categories: 1) The essential components of training include indepen-
  11. 11. JACC Vol. 41, No. 4, 2003 Quinones et al. ˜ 697February 19, 2003:687–708 ACC/AHA Clinical Competence Statement on EchocardiographyTable 10. Cognitive and Technical Skills Needed to Perform Table 11. Skills Necessary to Perform PerioperativePerioperative Echocardiography at a Basic Level Echocardiography at the Advanced LevelCognitive Skills Cognitive Skills● Basic knowledge outlined in Table 2. ● All the cognitive skills defined for the basic level.● Knowledge of the equipment handling, infection control, and ● Knowledge of the principles and methodology of quantitative electrical safety recommendations associated with the use of TEE. echocardiography.● Knowledge of the indications and the absolute and relative ● Detailed knowledge of native valvular anatomy and function. contraindications to the use of TEE. Knowledge of prosthetic valvular structure and function. Detailed● General knowledge of appropriate alternative diagnostic modalities, knowledge of the echocardiographic manifestations of valve lesions especially transthoracic and epicardial echocardiography. and dysfunction.● Knowledge of the normal cardiovascular anatomy as visualized by ● Knowledge of the echocardiographic manifestations of CHD*. TEE. ● Detailed knowledge of echocardiographic manifestations of pathologic● Knowledge of commonly encountered blood flow velocity profiles as conditions of the heart and great vessels (such as cardiac aneurysms, measured by Doppler echocardiography. hypertrophic cardiomyopathy, endocarditis, intracardiac masses,● Detailed knowledge of the echocardiographic presentations of cardioembolic sources, aortic aneurysms and dissections, pericardial myocardial ischemia and infarction. disorders, and post-surgical changes).● Detailed knowledge of the echocardiographic presentations of normal ● Detailed knowledge of other cardiovascular diagnostic methods for and abnormal ventricular function. correlation with TEE findings.● Detailed knowledge of the physiology and TEE presentation of air embolization. Technical Skills● Knowledge of native valvular anatomy and function, as displayed by ● All the technical skills defined for the basic level. TEE. ● Ability to perform a complete TEE examination.● Knowledge of the major TEE manifestations of valve lesions and of ● Ability to quantify subtle echocardiographic changes associated with the TEE techniques available for assessing lesion severity. myocardial ischemia and infarction.● Knowledge of the principal TEE manifestations of cardiac masses, ● Ability to utilize TEE to quantify ventricular function and thrombi, and emboli; cardiomyopathies; pericardial effusions and hemodynamics. lesions of the great vessels. ● Ability to utilize TEE to evaluate and quantify the function of all cardiac valves including prosthetic valves (e.g., measurement ofTechnical Skills pressure gradients and valve areas, regurgitant jet area, effective● Ability to operate the ultrasound machine, including controls affecting regurgitant orifice area). Ability to assess surgical intervention on the quality of the displayed data. cardiac valvular function.● Ability to perform a TEE probe insertion safely in the anesthetized, ● Ability to utilize TEE to evaluate congenital heart lesions. Ability to intubated patient. assess surgical intervention in CHD*.● Ability to perform a basic TEE examination. ● Ability to detect and assess the functional consequences of pathologic● Ability to recognize major echocardiographic changes associated with conditions of the heart and great vessels (such as cardiac aneurysms, myocardial ischemia and infarction. hypertrophic cardiomyopathy, endocarditis, intracardiac masses,● Ability to detect qualitative changes in ventricular function and cardioembolic sources, aortic aneurysms and dissections, and hemodynamic status. pericardial disorders). Ability to evaluate surgical intervention in these● Ability to recognize echocardiographic manifestations of air conditions if applicable. embolization. ● Ability to monitor placement and function of mechanical circulatory● Ability to visualize cardiac valves in multiple views and recognize assistance devices. gross valvular lesions and dysfunction. *Requires additional training as outlined in the Section on CHD.● Ability to recognize large intracardiac masses and thrombi. CHD congenital heart disease.● Ability to detect large pericardial effusions.● Ability to recognize common artifacts and pitfalls in TEE examinations. defined by the ASE and SCA (9). A basic practitioner● Ability to communicate the results of a TEE examination to patients should be able to acquire all 20 of the recommended and other health care professionals and to summarize these results cross-sections, although not always needed for a basic cogently in the medical record. examination, in the event they are needed for remoteAbbreviation same as Table 7. consultation with an advanced practitioner. For basic train- ing, 150 complete examinations should be studied underdent work, supervised activities, and assessment programs. appropriate supervision. These examinations must includeThrough a structured independent reading and study pro- the full spectrum of commonly encountered perioperativegram, trainees must acquire an understanding of the prin- diagnoses and at least 50 comprehensive perioperative TEEciples of ultrasound and indications for perioperative echo- examinations personally performed, interpreted, and re-cardiography. This independent work should be ported by each trainee (Table 12).supplemented by regularly scheduled didactics such as For advanced practice, the comprehensiveness of traininglectures and seminars designed to reinforce the most im- is paramount. The ASE/SCA Task Force (11) recommendsportant aspects of perioperative echocardiography. Under that 300 complete examinations be studied under appropri-appropriate supervision, trainees undergoing basic training ate supervision. These examinations must include a widelearn to place the TEE probe, operate the ultrasound spectrum of cardiac diagnoses and at least 150 comprehen-machine, and perform a TEE examination. Trainees should sive perioperative TEE examinations that are personallybe encouraged to master the comprehensive examination performed, interpreted, and reported by the trainee (Table
  12. 12. 698 Quinones et al. ˜ JACC Vol. 41, No. 4, 2003 ACC/AHA Clinical Competence Statement on Echocardiography February 19, 2003:687–708Table 12. Training Recommendations for Basic and Advanced Perioperative Echocardiography Basic AdvancedMinimum number of examinations studied 150 300Minimum number personally performed 50 150Program director qualifications advanced perioperative echocardiography advanced perioperative echocardiography training, plus at training least 150 additional perioperative TEE examinationsProgram qualifications wide variety of perioperative applications full spectrum of perioperative applications of of echocardiography echocardiographyAbbreviations same as in Table 7.12). For both basic and advanced training, trainees must be and learn to use TEE effectively in all its establishedtaught how to convey and document the results of their perioperative applications. The perioperative echocardiog-examination effectively. Periodic formal and informal eval- raphy training program should have an affiliation with anuations of trainees’ progress should be conducted during echocardiography laboratory so that trainees can gain regu-training. Trainees should keep a log of the examinations lar and frequent exposure to teaching and clinical resourcesthey performed and reviewed to document the depth and within that laboratory.breadth of their training. The experience and case numbers Proof of Competence (Table 13). Documentation ofacquired during basic training may be counted toward competence can be achieved by means of letters or certifi-advanced training if the basic training was completed in an cates from the director of the perioperative echocardiogra-advanced training environment. phy training program. This documentation should state the The ASE/SCA Task Force and this writing group dates of training and that trainees have successfully achievedrecognize that trainees from different specialties will allocate or surpassed each of the training elements.their training schedules somewhat differently depending on Physicians already in practice can achieve appropriatetheir backgrounds. A cardiologist-echocardiographer with training in perioperative echocardiography without enroll-little operating room experience will need to spend more ing in a formal training program. However, the sametime in this environment to fully understand cardiac surgical prerequisite medical knowledge, medical training, and goalstechniques. A cardiac anesthesiologist or surgeon working for cognitive and technical skills apply to them as they applyin a center with a limited variety of cardiac surgery will need to physicians in formal training programs. They shouldto spend more time in the echocardiographic laboratory to work with other physicians who have advanced TEE train-fully understand all of the diagnostic techniques in echocar- ing or equivalent experience to achieve the same trainingdiography. Advanced training should take place after basic training goals and case numbers as the training levels previouslyin a training program designed specifically to accomplish delineated. It is the consensus of this writing group thatcomprehensive training in perioperative echocardiography. physicians seeking basic training via this pathway shouldThe director of the training program must be a physician have at least 20 hours of CME devoted to echocardiogra-with advanced training and proven expertise in perioperative phy. Physicians seeking advanced training via this pathwayechocardiography, who has performed at least 450 complete should have at least 50 hours of CME devoted to echocar-examinations, including 300 perioperative TEE examina- diography. The CME in echocardiography should be ob-tions or equivalent experience. As advanced trainees acquire tained during the time that trainees are acquiring themore experience, they may be allowed to work with more requisite clinical experience in TEE. Trainees should doc-independence, but the immediate availability and direct ument their experience in detail and be able to demonstrateinvolvement of an advanced practitioner is an essential training equivalent in depth, diversity, and case numbers tocomponent of advanced training. The supporting surgical the training levels previously delineated. Physicians whoprogram must have the volume and diversity to ensure that provide the training should document the successful com-trainees will experience the wide spectrum of diagnostic pletion of the training elements and the dates of training.challenges encountered in perioperative echocardiography We believe that, ideally, physicians should take the periop- Table 13. Documentation and Maintenance of Competence in Perioperative TEE Documentation of Competence Maintenance of Competence Letter or certificate from the director of the perioperative Performance and interpretation of at least 50 echocardiography-training program (For physicians in examinations practice: a letter from the physician providing the Participation in Continuous Quality training documenting the successful completion of the Improvement training elements and the dates of training) Participation in Continuous Medical Education or as outlined in Section A NBE certification

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