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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
VIII.
Fetal Echocardiography
Overview
and Indications for the Procedure. Fetal echocardiography
is the ultrasonic evaluation of the developing human cardiovascular
system prior to birth. Non-invasive in nature, and highly
accurate when used by skilled operators, it is presently the
standard method used for the detection of fetal cardiovascular
disease. A complete imaging evaluation of the fetal cardiovascular
system can be obtained utilizing a maternal trans-abdominal
approach at 18 to 22 weeks gestation; however, some images
can be obtained as early as 14 to 16 weeks. Trans-vaginal
fetal echocardiography can be performed as early as 12 weeks
gestation. The increasing national trends toward routine performance
of second trimester obstetrical ultrasound, and toward overall
improvements in the field of obstetrical diagnostics have
led to a greater number of referrals to specialists knowledgeable
in the field of fetal cardiovascular abnormalities and skilled
in the performance of fetal echocardiography. Recent data
demonstrate an improved postnatal outcome for CHD when a prenatal
diagnosis via fetal echocardiography is made (17,18).
The
practice of fetal echocardiography is unique for a number
of reasons. Management of fetal heart disease involves multiple
services that care for both mother and fetus. The practice
of fetal echocardiography must therefore take place within
the context of a multidisciplinary approach offering expertise
in pediatric cardiology, maternal-fetal medicine, genetics,
neonatology, and pediatric cardiac surgery. The practitioner
of fetal echocardiography must have a basis of clinical understanding
in all of these fields in order to interact knowledgeably
and coordinate care. The detection of fetal cardiovascular
disease via fetal echocardiography can have a significant
impact on the course of the pregnancy. Information generated
by the fetal echocardiographer will commonly result in parental
counseling, which may contribute to decisions concerning the
continuation of pregnancy, initiation of treatment, or determination
of the place for labor and delivery. Due to the physiologic
differences inherent in postnatal and prenatal life, congenital
anomalies of the fetal heart are observable but do not commonly
manifest clinically until after birth. The time lag between
the detection of structural CHD in the fetus and intervention
after birth provides an opportunity to offer counseling, genetics
evaluation, and education to expectant parents, all of which
contributes to appropriate preparation.
Many
disease processes including congenital fetal anomalies, acquired
fetal disorders, maternal disorders, and exposure to offending
agents can lead to abnormalities in fetal cardiovascular development
and can thereby warrant examination by a qualified fetal echocardiographer.
Indications for fetal echocardiography can be categorized
as either maternal or fetal in nature. Examples of maternal
indications include: a family history of CHD, diabetes, connective
tissue disease, and teratogen exposure. Examples of fetal
indications include: an abnormal-appearing heart on routine
obstetrical ultrasound, non-immune hydrops, an irregularity
of fetal heart beat, chromosomal abnormality, and the discovery
of extra-cardiac anomalies (i.e., congenital lung lesions,
diaphragmatic hernia).
Minimum
Knowledge Required for Performance and Interpretation (Table
21). Competence in performing and/or interpreting
fetal echocardiography requires all of the basic knowledge
of ultrasound physics, of instrumentation, and of cardiac
anatomy, physiology, and pathology described in the section
on General Principles. In addition, the physician performing
fetal echocardiography must be knowledgeable in the principles
of biological ultrasound instrumentation and its application
in human pregnancy. A thorough understanding of maternal-fetal
physiology, as well as maternal diseases that may affect the
developing fetus, is necessary. The physician performing fetal
echocardiography should be familiar with the latest developments
in obstetrical diagnostics, including which invasive and noninvasive
tests are available throughout the trimesters of pregnancy.
A thorough understanding of and an ability to recognize the
full spectrum of simple and complex, acquired and congenital,
heart disease are mandatory. The physician must have knowledge
of cardiac embryology and the anatomy and physiology of the
developing cardiovascular system throughout the stages of
human development. A thorough understanding of fetal physiology
and the impact of heart disease on fetal physiology is necessary,
along with an understanding of the potential impact that labor
and delivery have on the fetal cardiovascular system.
Commonly,
parental counseling is offered to expectant parents by fetal
echocardiographers. Hence, fetal echocardiographers must have
good communicative skills, a high level of compassion, and
a thorough understanding of the prognosis and outcome of CHD
in the 21st century. This understanding must include knowledge
of the most recent developments in surgical correction for
complex CHD, and the most current data concerning long-term
outcome. The highest standards of ethics are expected, and
fetal echocardiographers should be able to deliver information
in an objective, non-directive manner.
Physicians
performing fetal echocardiography must be skilled in the technical
aspects of the examination. The fetal echocardiogram involves
imaging in multiple tomographic planes that provide a three-dimensional
understanding of fetal cardiac structure, function, and flow.
Two-dimensional imaging should be followed by color Doppler
imaging and pulsed-, or continuous-wave Doppler imaging of
the inflow and outflow portions of the heart, the atrial and
ventricular septae, and the venous and arterial structures.
Doppler analysis of umbilical cord vessels, which can provide
important information concerning placental function, should
be included. Observation and analysis of the fetal heart rate
and rhythm via Doppler techniques or M-Mode techniques should
be performed.
Training
Requirements (Table 22). Training
for fetal echocardiography should take place under the direction
of a skilled and dedicated expert in fetal echocardiography.
The training center should be one in which a large number
of fetal echocardiographic studies are performed and which
has a strong integrated relationship with specialists in maternal
fetal medicine. In order to obtain the necessary knowledge
base and breadth of understanding of CHD, board certification
in, or eligibility for pediatric cardiology should be achieved.
Familiarization with fetal cardiovascular disease and exposure
to the interpretation of fetal echocardiograms take place
during fellowship training in pediatric cardiology. This introductory
experience (Level 1 competence) may be spread throughout the
fellowship training period and should consist of exposure
to a variety of fetal echocardiographic cases. Since fetal
echocardiography is a complex, specialized form of echocardiographic
examination requiring a high level of skill, such minimal
exposure does not provide sufficient training to independently
perform, or clinically interpret, fetal echocardiograms.
Guidelines
for physician training in fetal echocardiography were offered
by the Society of Pediatric Echocardiography Committee on
Physician Training in 1990 (19).
We endorse these recommendations. In order to achieve the
minimal skills necessary to independently perform and interpret
fetal echocardiograms, advanced training beyond that offered
during the standard pediatric cardiology fellowship is necessary.
Trainees interested in obtaining these minimal skills (Level
2 competence) should perform and interpret 25 fetal echocardiography
cases and participate in the interpretation or review of an
additional 25 cases under the supervision of a skilled, dedicated
fetal echocardiographer. These cases should include a wide
variety of simple and complex CHD, as well as extra-cardiac
diseases affecting the fetal cardiovascular system. During
this period, trainees should be exposed to multidisciplinary
maternal fetal clinical care conferences and participate in
the care and management of the fetus with cardiovascular disease.
In
order to achieve sufficient skills and the confidence necessary
to perform and interpret fetal echocardiograms independently,
assume responsibility for training other physicians, and direct
a fetal echocardiography laboratory (Level 3 competence),
a supplemental period of time dedicated to fetal echocardiography
training beyond the three years of pediatric cardiology fellowship
training is recommended. This should be performed under the
supervision of a skilled and experienced fetal echocardiographer.
During this period of time, trainees should participate in
the performance and interpretation of at least 100 fetal echocardiography
cases. These cases should include a wide variety of simple
and complex CHD as well as extra-cardiac diseases affecting
the fetal cardiovascular system. A portion of this training
period should be spent in the performance and interpretation
of general obstetrical ultrasound examinations in cooperation
with maternal-fetal medicine services. Trainees should participate
in multidisciplinary maternal-fetal clinical care conferences
and in the care and management of the fetus with cardiovascular
disease. Trainees should be encouraged to participate in research
endeavors that will enhance the field of fetal cardiovascular
disease.
Proof
of Competence (Table 23). Proof
of competency is achieved by a letter or certificate from
the program training director or physician responsible for
supervising trainees, confirming the time dedicated to training
in fetal echocardiography and the number of fetal echocardiograms
performed. For individuals who completed training before 1990,
documentation of performance and interpretation of a similar
number of cases as previously indicated is required, along
with documentation of participation in maternal-fetal clinical
care conferences in which cases concerning fetal cardiovascular
disease were reviewed. There is presently no examination available
to test competence in fetal echocardiography.
Maintenance
of Competence (Table 23). Maintenance
of competence in fetal echocardiography should be achieved
by continuing activity in performance and interpretation of
studies as well as active participation in the care of the
fetus with cardiovascular disease. Minimal competence (Level
2) can be maintained by performance and/or interpretation
of at least 25 fetal echocardiography cases per year, while
those seeking to maintain Level 3 skills should perform and/or
interpret a minimum of 100 fetal echocardiography cases per
year. Evidence of continued learning and acquisition of new
knowledge in the field via attendance at scientific meetings
and conferences is required.
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