American College of Cardiology

Quinones ET AL., ACC/AHA CLINICAL COMPETENCE STATEMENT ON ECHOCARDIOGRAPHY
J Am Coll Cardiol 2003;41:687-708

ACC/AHA Clinical Competence Statement on Echocardiography

A Report of the American College of Cardiology/American Heart
Association/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence

Developed in Collaboration with the American Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, and the Society of Pediatric Echocardiography

IV. Transesophageal Echocardiography

Overview and Indications for the Procedure. Transesophageal echocardiography provides an excellent window for examining the heart and great vessels. Its clinical applications include, but are not limited to: detection and assessment of endocarditis and its complications, aortic dissection and other aortic pathologies, intracardiac thrombi and other masses, evaluation of valvular disorders including prosthetic valve function, and evaluation of a variety of CHDs in both children and adults. Transesophageal echocardiography is also of great use in patients with suspected cardiac trauma, in critically ill medical or surgical patients with unstable hemodynamics, and in patients whose clinical status necessitates echocardiographic assessment but in whom TTE studies are technically inadequate or nondiagnostic. In many large echocardiography laboratories, TEE studies represent between 5% and 10% of the total volume of echocardiographic examinations.

Transesophageal echocardiography is a minimally invasive procedure with small but definite risks.⁽⁷⁾ Therefore, it should be reserved for clinical circumstances in which the potential findings have significant implications for patient management and cannot be obtained by transthoracic evaluation.

Minimum Knowledge Required for Performance and Interpretation (Table 7). Competence in performing and interpreting TEE in adult patients requires all of the basic knowledge of ultrasound physics and instrumentation as well as the cardiac anatomy, physiology, and pathology described in the section on General Principles. The specific cognitive and technical skills needed to perform TEE in a competent manner are listed in Table 7.⁽⁸⁾

Transesophageal echocardiography requires the insertion of an endoscopic probe into the esophagus and manipulating the probe through multiple imaging planes to obtain tomographic views of the heart and great vessels. To reduce the level of discomfort associated with the procedure, a topical anesthetic spray is administered to the oropharynx, and intravenous conscious sedation is often used. Consequently, the physician performing a TEE must be knowledgeable with regard to: pharyngeal and esophageal anatomy; the proper use of conscious sedation, including the prompt recognition of possible complications; the various techniques of esophageal intubation and probe manipulation; the recognition and management of possible complications of probe insertion, including the infrequent occurrence of methemoglobinemia as a complication of benzocaine administration; and the absolute and relative contraindications to the performance of a TEE examination. The operator must also have the necessary technical knowledge required to operate the ultrasound machine. Importantly, the physician performing a TEE needs good communication skills in order to explain the TEE procedure to patients in simple terms, including its risks, benefits, and alternative approaches—and in order to obtain the patient's cooperation during the examination. In many patients, the results of a TEE examination guide urgent and definitive treatment (such as emergency surgery in a patient with an ascending aortic dissection); thus, the physician performing a TEE needs to have a thorough knowledge of cardiovascular disorders and their accompanying hemodynamic alterations, the different diagnostic issues that require consideration given a particular clinical presentation, and the potential therapies available. The operator also needs to have mastered a thorough understanding of the basic principles of ultrasound imaging and Doppler hemodynamic assessment described in detail in the previous sections.

Although it is usually preferable to perform a comprehensive and systematic TEE examination, it is not always possible, particularly in critically ill patients. Consequently, it is essential that the operator evaluate the most pressing diagnostic issues first. Therefore, the physician performing a TEE must be able to review available clinical and diagnostic information, including data from the TTE, in order to prioritize the most relevant issues and focus the TEE examination on resolving these issues.

Training Requirements (Table 8). The proper performance and interpretation of the TEE examination requires training in a number of elements such as: appropriate use of sedatives, proper and safe introduction of the TEE probe, manipulation of the TEE transducer, optimization of the echocardiographic instrument, correct interpretation of the study findings, and communication of findings to other healthcare providers in an articulate and effective manner. This training is best obtained during a formal fellowship in cardiovascular medicine, or its equivalent, and through active participation in a training program in general TTE. Alternatively, the training can be achieved as part of a cardiovascular anesthesiology or critical care medicine fellowship, with a formal period of intensive education in an affiliated diagnostic echocardiography laboratory.

Specifically, trainees must perform esophageal intubations (using a diagnostic TEE probe) under the tutelage of an experienced physician with advanced skills in TEE or under the supervision of an experienced endoscopist. Trainees must also perform a number of TEE examinations under the tutelage of an experienced TEE operator before performing TEE examinations independently. It is crucial that trainees learn to recognize normal and abnormal findings "on-line" and to manipulate the probe to obtain optimal views for evaluating the abnormalities observed. Because the results of a TEE examination are frequently considered "definitive" and used to make immediate and important management decisions, we do not believe in defining different levels of competence. Therefore, in regard to TEE, "minimum training" and "optimal training" are the same. We endorse the previously published recommendations of the ASE ⁽⁸⁾ and the ACC.⁽⁴⁾

For physicians in formal cardiology fellowship training programs, training in TEE should include 1) attainment of at least Level 2 experience in general TTE; 2) performance of approximately 25 esophageal intubations with a TEE probe; and 3) performance of approximately 50 diagnostic TEE examinations under the supervision of an experienced (Level 3) echocardiographer, including the review, interpretation, and reporting of study findings. It is important to emphasize that in certain specialized clinical circumstances, even this training may not be sufficient for the independent performance of a TEE. For example, assessment of complex congenital heart lesions, and intraoperative evaluation of the suitability for and results of surgical repair of valvular regurgitation, are particularly demanding and require additional training and expertise.

Physicians who are not enrolled in a cardiology fellowship-training program need to acquire similar knowledge and to develop similar skills. This could be accomplished through an intensive period of training in an active TEE training program or through ongoing training under the guidance and supervision of an experienced (Level 3) echocardiographer with significant expertise in TEE.

Proof of Competence (Table 9). Documentation of competence can be achieved by means of a letter or certificate from the director of the echocardiography laboratory in which the trainee obtained TEE training or from the training program director, with input from the echocardiography laboratory director. This documentation should state that the trainee successfully achieved or surpassed each of the training elements, and the dates of training. For physicians whose training in echocardiography was completed before July 1, 1998, a Level 2 equivalence in TTE should be documented, as detailed in the previous section. In addition they must document performance of a minimum of 50 TEE cases per year, for the preceding two years. We believe that ideally, physicians should take the board examination offered by the NBE, and achieve certification in the relevant practice areas of echocardiography (i.e., general transthoracic, TEE, stress echocardiography, or comprehensive certification).

Maintenance of Competence (Table 9). Maintenance of competence in TEE requires both ongoing continuing education and regular performance of TEE examinations. Physicians performing TEE examinations should periodically attend postgraduate courses and workshops that focus on clinical applications of TEE, especially those that emphasize new and evolving techniques and developments. In addition, physicians should seek to compare the quality, completeness, and results of their own examinations with those presented at scientific meetings and in professional publications. On-line or other multimedia formats give physicians increasing access to a variety of materials that can help them keep up with the field.

Ongoing performance of diagnostic TEE examinations is needed to maintain technical skills and to keep up with developments in the field. Infrequent performance of TEE increases the risk of complications or of inaccurate results and inappropriate patient treatment. The guidelines on training in TEE published by the ASE in 1992 recommended performing 50 to 75 TEE examinations per year.⁽⁸⁾ Given the greater exposure to training in this modality over the past 10 years and recognizing that achieving such a volume may be difficult in routine clinical practice, this writing group recommends that a minimum of 25 to 50 cases per year be required to maintain adequate cognitive and technical skills in performing and interpreting TEE. Of course, TEE examinations should not be performed simply to meet these guidelines, but they must be indicated on clinical grounds and appropriate to good patient care. Physicians at the lower end of the recommended number should work in association with a laboratory where a greater volume is performed, so that they can be exposed to an adequate variety of pathology. On the other hand, physicians who cannot meet the recommended number should perform the procedure in conjunction with more experienced operators. Continuing medical education in echocardiography and TEE is essential to keep pace with ongoing technical advances, refinements in established techniques, and applications of new methods. Minimal CME requirements are outlined in Section A.

We also subscribe to the principles of Continuing Quality Improvement in Echocardiography, ⁽⁶⁾ and recommend that a random sample of TEE studies performed by an individual operator periodically be reviewed by a qualified expert (from the operator's own institution or, if necessary, from the outside), as part of a quality assessment program. This review should be performed in an educational and non-punitive manner and should help to determine if TEE studies had been performed for appropriate indications, if studies were of sufficient completeness and technical quality to resolve the relevant diagnostic questions, if findings were interpreted and reported correctly, and if results were reported in an effective and timely manner. Recurring variations from the norm would then serve to highlight areas for further quality improvement and thereby help facilitate better patient care. Continuing Quality Improvement considerations also mandate that the results of TEE examinations be compared, whenever possible, with the findings from cardiac catheterization or other cardiac imaging studies, cardiac surgery, or necropsy in order to establish and maintain diagnostic accuracy.