On the first day of my echocardiography rotation, I sat in a dimly-lit reading room in front of two large monitors displaying a complex echocardiogram of a patient with left ventricular systolic dysfunction and two prosthetic valves.

As I scrolled through the images, several questions came to mind. What image do I start with? What structure should I interpret first? How do I determine the ejection fraction? How are gradients interpreted differently in prosthetic valves? How do I use strain to help me assess left ventricular function?

Three years later, I have answers to many of those questions, or at least an approach to find the answers. Faculty and sonographer guidance, self-motivation and repetition all played critical roles in building my knowledge base and skillset. Accurate and precise interpretation of echocardiograms involves a multifaceted longitudinal training program with constant repetition, attention to breadth of experiences, and continuous assessment and evaluation.

The purpose of this article is to review the current expectations of echocardiography training and shed insight as to what the future holds for upcoming fellows.

Requirements of a Successful Echocardiography Training Program

In February, the ACC, American Heart Association (AHA) and American Society of Echocardiography (ASE) released a joint Advanced Training Statement focusing on core competencies expected of all individuals who interpret echocardiograms, as well as advanced competencies specific to Level III echocardiographers.

This document reflects several iterations of training recommendations, the first of which was published in 1995 based on expert opinion from a core cardiology training symposium. The most recent document prior to this was the COCATS 4 Task Force 5 report, which outlined all basic training components but did not address the requirements for Level III echocardiology training in detail.

As the echocardiography practices continue to evolve and become more sophisticated, this document provides a contemporary guide for level III echocardiographer competencies.

The general principles of a superior level III training program include faculty who are invested in the mission of education; adequate facilities and equipment to support the in-depth clinical experience; a learning environment enriched with collaboration across cardiology and other specialties; and exposure to other venues of cardiac ultrasound including point-of-care studies. Fellows should be exposed to a wide range of pathologies in a variety of clinical settings.

While there are specific minimum procedural volume numbers published in the guideline, the true benchmark is competency and mastery of the material by the end of the fellowship. Details of the key components of Level III echocardiography education are illustrated in Figure 1.

Longitudinal overlying themes that mark excellent training program are rigorous clinical experience, research and scholarly activity, as well as continuous evaluation of proficiency.

Best Practices in Echocardiography Education

The ACC/AHA/ASE training statement is based on expert consensus and very little on rigorous outcome-based data. While sparse, there is some data to guide determination of best practices for teaching echocardiography interpretation. In 2016, Emily Ruden, MD, et al., performed a literature review of studies describing methods for teaching echocardiography.

Two salient teaching methods that resulted in more accurate echocardiographic reporting included focused curriculum-based teaching (either through an intense didactic series or case-based longitudinal experience) and simulation. Personally, I have found simulation to be an effective method of mastering procedural aspects of echocardiography throughout my own training, including transthoracic and transesophageal image acquisition.

Simulation mannequins – the gold standard for hands-on learning – are effective but can be cumbersome and expensive for some programs. An alternative is online simulation and case-based training modules such as those produced by KeLabs.

Another such easily accessible online tool is the Virtual Transesophageal Echocardiography (TEE) website created by faculty at the University of Toronto. Using this platform, fellows can learn basic anatomical views in a standard TEE protocol as well as practice unconventional views in anticipation for challenging cases.

Frontiers in Echocardiography Education

The future of echocardiography education lies in virtual reality. There has been outstanding work converting multiple static 3D images into virtual reality experiences that have enabled clinicians to take a deeper dive into cardiac anatomy and pathophysiology.

The educational implications of virtual reality are boundless, from basic understanding of cardiac anatomy to simulating the exact path and hemodynamics that a red blood cell experiences as it travels throughout the heart and vasculature (including influences of regurgitant jets and stenotic valves).

As illustrated by Roberto M. Lang, MD, et al, 3D can clinically translate for evaluating patients for valve-in-valve implantations. As the number of structural interventions increases and procedures become more complex, the use of real-time, 3D echocardiographic guidance will follow.

Therefore, training programs will have to place a greater emphasis on intraprocedural education and training, spanning transthoracic and transesophageal imaging. Virtual reality provides a venue for gaining skills before trainees are expected to perform in complex, high stakes clinical scenarios.