The introduction of transesophageal echocardiography (TEE) in the perioperative setting has greatly improved the ability of the anesthesiologist to care for surgical patients with cardiovascular disease. Recognizing this, the National Board of Echocardiography (NBE) was established in 1998 to develop and administer examinations, and publically recognizes physicians who have successfully completed a board certification process for perioperative echocardiography. The scope of practice for physicians who achieve advanced certification involves the full diagnostic potential of TEE including guiding surgical interventions.
The utility of TEE in the perioperative setting is not limited to patients undergoing cardiac surgery. As an anesthesiologist, I frequently care for patients with cardiac disease undergoing non-cardiac surgery and occasionally have unexplained hemodynamic instability in these patients. Recently, I was taking care of a patient who was undergoing an open abdominal aortic aneurysm repair and during a critical portion of the procedure became significantly hypotensive. My initial diagnosis was hypovolemia, and I began treatment with volume replacement and phenylephrine as a temporizing agent. Unfortunately, the patient failed to improve with this therapy. Because of this, I quickly placed a TEE probe, only to find that the etiology of the hypotension was cardiogenic and not hypovolemia. This information allowed me to alter my treatment and ultimately achieve a good outcome for the patient. The information I obtained from a focused TEE exam was invaluable in allowing proper care for my patient.
Recognizing the benefits of perioperative TEE, the American Society of Anesthesiologists (ASA) House of Delegates mandated the development of a program focused on education and training in basic echocardiography skills in October 2006. Working through a collaborative effort, the ASA and the Society of Cardiovascular Anesthesiologists (SCA) have developed a program that offers 4 courses annually to provide training in basic echocardiography for all anesthesiologists. In 2009, the ASA and NBE established a partnership to promote an examination and certification in basic perioperative TEE. The purpose of perioperative TEE certification is to establish the domain of practice of perioperative TEE, assess the knowledge of perioperative TEE, enhance the quality of perioperative TEE, and recognize physicians who have satisfied the NBE requirements. The scope of practice for basic TEE certification is limited to non-diagnostic use within the customary practice of anesthesiology. The intention of the basic TEE certification is not to replace the advanced certification process and does not qualify one to guide intraoperative cardiac surgical interventions. Guidelines for what constitutes a basic TEE exam are currently being developed by the Intraoperative Council of the ASE and will include knowledge of basic principles of echocardiography, patient safety concerns, and instructions on a focused examination.
Two pathways are available for certification. The supervised training pathway requires maintenance of current board certification in anesthesiology and study of 150 basic perioperative TEE examinations under supervision. Of the 150 required TEE examinations, 50 must be personally performed and interpreted. Supervised training in basic perioperative TEE must be obtained from an ACGME or another national accreditation agency accredited anesthesiology residency program, and must be accomplished within a four year period of time. In addition to these clinical prerequisites, successful completion of the basic perioperative TEE exam is required. The content outline of this exam can be found on the NBE’s Web site, www.echoboards.org .
The practice experience pathway requires that applicants perform and interpret at least 150 basic intraoperative TEE examinations within four (4) consecutive years immediately preceding application, with no less than 25 in any of the four years. Physicians seeking certification by this pathway must have at least 40 hours of AMA category 1 continuing medical education devoted to perioperative TEE obtained during the time the physician is acquiring the requisite clinical experience in TEE.
Upon successful completion of the basic perioperative TEE certification, anesthesiologists will have the echocardiographic knowledge and skill to improve outcomes in surgical patients with cardiovascular disease.