Cardiovascular ultrasound is a common and important imaging technique to assess cardiac anatomy and function. Three levels of training pertain to echocardiography; this advanced training statement on echocardiography (a collaboration between the American College of Cardiology, American Heart Association, American Society of Echocardiography, American Thoracic Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Critical Care Medicine) describes Level III training guidelines. The following are key points to remember:

Level III Training

1. Level III training in echocardiography requires additional experience beyond the basic cardiovascular fellowship; and is required of individuals who intend to perform and interpret complex studies in special populations, lead a research program, direct an academic echocardiography laboratory, or train others in advanced aspects of echocardiography. Although Level III training in echocardiography may be achieved within a standard 3-year fellowship, for many individuals, an additional period of postgraduate training will be required.

General Standards

2. Faculty: Trainees should have access to an engaged faculty committed to teaching.
3. Facilities and equipment: Trainees should have access to patients with a broad range of outpatient and inpatient diagnoses; and ultrasound equipment and off-line workstations for performance and interpretations of transthoracic (TTE) and transesophageal echocardiography (TEE), Doppler echo, contrast echo, stress echo, and strain imaging.
4. Additional resources: Additional resources accessible to the trainee should include experienced sonographers committed to teaching; and routine exposure to cardiologists from other subspecialties, and practitioners from other fields including surgeons, infectious disease specialists, pulmonologists, neurologists, anesthesiologists, and interventionalists.

Training Components

5. Didactic program: A didactic program should provide the advanced trainee with an understanding of ultrasound physics, instrumentation, echocardiographic image formation and optimization, and clinical applications of echocardiography (including contrast agents, strain imaging, 3D echocardiography, stress echo, and TEE). Instruction in the use of echocardiography in structural heart interventions and cardiac surgery should be included. Level III didactic teaching should be in a multimodality imaging framework to emphasize appropriate and coordinated use of all cardiac imaging modalities.
6. Clinical experience: Exposure to the entire spectrum of heart diseases in diverse (acquired and congenital) patient populations should be available to the trainee. Although a minimum number of clinical cases is suggested (below), these criteria only serve as proxies for clinical experience.
7. Hands-on procedural experience: Because Level III training requires that the trainee be able to train both fellows and sonographers in image acquisition and optimization at the level of a skilled cardiac sonographer, fully developed image acquisition skills are an essential competency for the Level III trainee.
8. Diagnosis and management of emergencies and complications: Emergency echocardiography is the use of echocardiography (TTE or TEE) for the rapid diagnosis of unstable patients, life-threatening conditions, or procedural/surgical complications; it requires that the examination is performed and interpreted by an individual able to acquire the needed information, formulate an accurate interpretation, integrate the echo data with the clinical scenario, and immediately communicate the relevant information to the healthcare team. The Level III trainee should be fully trained in all aspects of TTE and TEE techniques; including the recognition and assessment of life-threatening conditions including left ventricular dysfunction, cardiac tamponade, right heart failure, acute valvular regurgitation, and aortic dissection.
9. Diagnosis and management of rare clinical conditions and syndromes: Level III trainees should be familiar with the echocardiographic findings of less common conditions involving the cardiovascular system, including (repaired and unrepaired) complex congenital heart defects, the full spectrum of acquired and genetic cardiomyopathies, and the various etiologies of cardiac masses.
10. Research and scholarly activity: An important purpose of Level III training is to develop the skills necessary for a career that includes cardiovascular research and education. Formal training in research methodology should be available for fellows who plan to be involved in research. Research should lead to presentations at local, regional, and/or national meetings; publication in peer-reviewed scientific journals; and/or grant support. Level III trainees at programs that are not designed to support original research activities should actively participate in quality improvement and educational projects.

Training Requirements

11. Development and evaluation of core competencies: Advanced training competencies for Level III echocardiographers are organized using the six domains used by the ACGME/ABMS and endorsed by the ABIM: Medical Knowledge, Patient Care and Procedural Skill, Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills.
12. Procedural and technical experience: Procedural and technical experience should include Level III general training requirements, and specific ultrasound procedures including TTE (≥150 studies performed and ≥750 interpreted), TEE (≥150 studies performed and interpreted), 3D-echo (≥50 studies each for valve disease/image manipulation, and for ventricular volumes and function), contrast echo (≥100 studies), strain echo (≥50 studies), and stress echo (≥200 studies, including 25 for noncoronary indications). Level III training also should include exposure to echo during interventional procedures (≥75 procedures), intraoperative TEE (≥75 procedures), and intracardiac echo (≥10 studies).
13. Training in multiple modalities: Echo trainees also should acquire Level I training in other noninvasive imaging modalities.

Leadership and Administrative Competencies

14. In addition to clinical competency, Level III trained echocardiographers are expected to function effectively as leaders in allied efforts to assure high-quality care and promote individual and population health, potentially including involvement in administrative roles in clinical practice, hospitals, health systems, professional societies, or other organizations.

Evaluation of Proficiency

15. Evaluation of an advanced trainee's proficiency involves multiple assessments, including global evaluations, direct observation, case logs, chart review, review of the trainee's portfolio of scholarly productivity and quality improvement projects, and assessment of leadership skills.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Cardiac Imaging Techniques, Cardiac Tamponade, Cardiomyopathies, Clinical Competence, Diagnostic Imaging, Echocardiography, Echocardiography, Doppler, Echocardiography, Stress, Echocardiography, Transesophageal, Education, Medical, Heart Defects, Congenital, Heart Failure, Multimodal Imaging, Patient Care, Quality Improvement, Teaching, Ultrasonography, Ventricular Dysfunction, Left

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