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

V. Perioperative Echocardiography

Overview and Indications for the Procedure. Perioperative echocardiography refers to the application of echocardiographic examination techniques in patients undergoing surgical procedures (intraoperative echocardiography) and during the early postoperative period. Early echocardiographic examinations used epicardial echocardiographic probes that had limited clinical applicability. Today, the examination is performed predominantly through the transesophageal approach, although epicardial and epivascular techniques continue to play a role during surgery, particularly in the echocardiographic assessment of the thoracic aorta.

Perioperative echocardiography utilizes most of the echocardiographic modalities used in the non-operative setting. They include M-mode and two-dimensional imaging techniques as well as pulsed, continuous-wave and color flow Doppler. Most modern transesophageal probes have multiplane capabilities. The ASE and the Society of Cardiovascular Anesthesiologists (SCA) have published guidelines for the performance of a comprehensive perioperative multiplane transesophageal examination.⁽⁹⁾

The indications for perioperative echocardiography have been summarized by a task force of the American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists (ASA/SCA) and published as practice guidelines in 1996.⁽¹⁰⁾ They can be divided into two broad categories: 1) indications that lie within the customary practice of anesthesiology, such as the perioperative diagnosis of myocardial ischemia and infarction, the perioperative assessment of hemodynamics and ventricular function, and the perioperative diagnosis and management of cardiovascular collapse; and 2) indications that guide surgical decisions in the operating room. In this regard, cardiovascular lesions are diagnosed, and the information is used to influence the patient's surgical management. The results of surgical interventions may be assessed by echocardiography, and the findings may guide additional surgical therapy, if necessary. A physician should perform the perioperative echocardiographic examination. Although a sonographer may assist the physician, the physician must always be present to interpret the echocardiographic data and assist the surgeon in planning the surgical procedure.

Minimum Knowledge Required for Performance and Interpretation (Table 10). Competence in performing and interpreting perioperative echocardiography in adult patients requires basic knowledge of ultrasound physics, instrumentation, and cardiac anatomy, physiology, and pathology outlined in the section on General Principles. Although several guidelines describe the knowledge necessary to perform echocardiography, few have focused on the specific knowledge and skills necessary for the practice of perioperative echocardiography. Specific guidelines on training in perioperative TEE have been recently published by an ASA/SCA Task Force.⁽¹¹⁾ These recommendations which were developed mainly for anesthesiologists, recognized that perioperative echocardiography was practiced at different levels. Some anesthesiologists predominantly use echocardiography for monitoring purposes in the detection of myocardial ischemia or the evaluation of intracardiac hemodynamics and ventricular function (basic level), while others use the full diagnostic potential of echocardiography in the perioperative period (advanced level). The knowledge and skills necessary to practice perioperative echocardiography at the basic and advanced levels are summarized in Tables 10 and 11, respectively. For non-anesthesiologists who practice perioperative echocardiography, any necessary knowledge beyond what is listed in the tables relates to physiologic changes induced by anesthetic agents, mechanical ventilation, and cardiopulmonary bypass.

Training Requirements (Table 12). We endorse the recent ASA/SCA task force recommendation of two levels of training for perioperative echocardiography, basic and advanced ^(10,11). Both basic and advanced TEE training refer to specialized TEE training that extends beyond the minimum exposure to echocardiography that occurs during normal anesthesia residency training. Anesthesiologists with basic training are considered able to use TEE for indications that lie within the customary practice of anesthesiology. Anesthesiologists with advanced training are, in addition, able to utilize the full diagnostic potential of perioperative TEE.

The essential components of training include independent work, supervised activities, and assessment programs. Through a structured independent reading and study program, trainees must acquire an understanding of the principles of ultrasound and indications for perioperative echocardiography. This independent work should be supplemented by regularly scheduled didactics such as lectures and seminars designed to reinforce the most important aspects of perioperative echocardiography. Under appropriate supervision, trainees undergoing basic training learn to place the TEE probe, operate the ultrasound machine, and perform a TEE examination. Trainees should be encouraged to master the comprehensive examination defined by the ASE and SCA.⁽⁹⁾ A basic practitioner should be able to acquire all 20 of the recommended cross-sections, although not always needed for a basic examination, in the event they are needed for remote consultation with an advanced practitioner. For basic training, 150 complete examinations should be studied under appropriate supervision. These examinations must include the full spectrum of commonly encountered perioperative diagnoses and at least 50 comprehensive perioperative TEE examinations personally performed, interpreted, and reported by each trainee (Table 12).

For advanced practice, the comprehensiveness of training is paramount. The ASE/SCA Task Force ⁽¹¹⁾ recommends that 300 complete examinations be studied under appropriate supervision. These examinations must include a wide spectrum of cardiac diagnoses and at least 150 comprehensive perioperative TEE examinations that are personally performed, interpreted, and reported by the trainee (Table 12). For both basic and advanced training, trainees must be taught how to convey and document the results of their examination effectively. Periodic formal and informal evaluations of trainees' progress should be conducted during training. Trainees should keep a log of the examinations they performed and reviewed to document the depth and breadth of their training. The experience and case numbers acquired during basic training may be counted toward advanced training if the basic training was completed in an advanced training environment.

The ASE/SCA Task Force and this writing group recognize that trainees from different specialties will allocate their training schedules somewhat differently depending on their backgrounds. A cardiologist-echocardiographer with little operating room experience will need to spend more time in this environment to fully understand cardiac surgical techniques. A cardiac anesthesiologist or surgeon working in a center with a limited variety of cardiac surgery will need to spend more time in the echocardiographic laboratory to fully understand all of the diagnostic techniques in echocardiography.

Advanced training should take place after basic training in a training program designed specifically to accomplish comprehensive training in perioperative echocardiography. The director of the training program must be a physician with advanced training and proven expertise in perioperative echocardiography, who has performed at least 450 complete examinations, including 300 perioperative TEE examinations or equivalent experience. As advanced trainees acquire more experience, they may be allowed to work with more independence, but the immediate availability and direct involvement of an advanced practitioner is an essential component of advanced training. The supporting surgical program must have the volume and diversity to ensure that trainees will experience the wide spectrum of diagnostic challenges encountered in perioperative echocardiography and learn to use TEE effectively in all its established perioperative applications. The perioperative echocardiography training program should have an affiliation with an echocardiography laboratory so that trainees can gain regular and frequent exposure to teaching and clinical resources within that laboratory.

Proof of Competence (Table 13). Documentation of competence can be achieved by means of letters or certificates from the director of the perioperative echocardiography training program. This documentation should state the dates of training and that trainees have successfully achieved or surpassed each of the training elements.

Physicians already in practice can achieve appropriate training in perioperative echocardiography without enrolling in a formal training program. However, the same prerequisite medical knowledge, medical training, and goals for cognitive and technical skills apply to them as they apply to physicians in formal training programs. They should work with other physicians who have advanced TEE training or equivalent experience to achieve the same training goals and case numbers as the training levels previously delineated. It is the consensus of this writing group that physicians seeking basic training via this pathway should have at least 20 hours of CME devoted to echocardiography. Physicians seeking advanced training via this pathway should have at least 50 hours of CME devoted to echocardiography. The CME in echocardiography should be obtained during the time that trainees are acquiring the requisite clinical experience in TEE. Trainees should document their experience in detail and be able to demonstrate training equivalent in depth, diversity, and case numbers to the training levels previously delineated. Physicians who provide the training should document the successful completion of the training elements and the dates of training. We believe that, ideally, physicians should take the perioperative TEE board examination offered by the NBE and achieve certification in perioperative echocardiography.

Maintenance of Competence (Table 13). Clinical competence in perioperative echocardiography requires continued maintenance of skills in perioperative TEE including two-dimensional and Doppler examination. Upon completion of above training requirements, a minimum of performance and interpretation of 50 examinations per year is required to remain proficient in performing perioperative echocardiography. A program for continuous quality improvement in echocardiography should be employed as outlined in the ASE Continuous Quality Improvement document ⁽⁶⁾. Continuing medical education in perioperative 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.