1.1

Document Development Process

1.2

Background and Scope

Echocardiography is the most widely used and readily available imaging technique for assessing cardiovascular anatomy and function. Clinical application of ultrasound encompasses M-mode, 2-dimensional (2D), 3-dimensional (3D), pulsed, tissue, and continuous-wave Doppler and color-flow imaging. Echocardiography noninvasively provides diagnostic and prognostic information concerning cardiovascular anatomy, function (i.e., ejection fraction), hemodynamic variables (i.e., gradient or pressure), and flow disturbances by means of pulsed, continuous-wave, and color-flow Doppler imaging. Moreover, these cardiovascular parameters can be assessed at rest, as well as during conditions of increased hemodynamic demand such as exercise.

The Task Force was charged with updating previously-published standards for training clinical adult cardiovascular fellows on the basis of changes in the field since 2008 and as part of a broader effort to establish consistent training criteria across all aspects of cardiology. The changes herein address the necessary balance between the development of increasingly specialized and sophisticated echocardiographic techniques and the need to provide a broad and complete training experience within a 3-year fellowship period. The Task Force also updated previously published standards to address the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by the ACGME and ABMS. The background and overarching principles governing fellowship training are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before considering the details of training in a subdiscipline like echocardiography. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally over time.

For most areas of adult cardiovascular medicine, 3 levels of training are delineated:

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  Level I training , the basic training required for trainees to become competent consultants, is required by all fellows in cardiology and can be accomplished as part of a standard 3-year training program in cardiology. For echocardiography, Level I training is defined as an introductory or early level of competency in performing and interpreting transthoracic echocardiography (TTE) that is achieved during fellowship training but not sufficient to provide independent interpretation of results.

  
  
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  Level II training refers to the additional training in 1 or more areas that enables some cardiovascular specialists to perform or interpret specific diagnostic tests and procedures or to render more specialized care for patients and conditions. This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying examination, is available to measure specific knowledge, skills, or competence. Level II training in selected areas may be achieved by trainees during the standard 3-year cardiovascular fellowship, depending on their career goals and use of elective rotations. Level II training in echocardiography is required to provide independent interpretation of echocardiograms.

  
  
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  Level III training usually requires additional experience beyond the standard 3-year cardiology fellowship to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific procedures or render advanced, specialized care at a high level of skill and are defined by competency components and outcome metrics. The skills and experience achieved during Level III training prepare the trainee to perform and interpret complex studies in special populations, engage in research, direct an academic echocardiography laboratory, and train others in advanced aspects of echocardiography. These advanced competencies are usually not covered during the general cardiology fellowship, but require additional training during which they are integrated with training in other imaging modalities. For selected fellows wishing to attain advanced competencies in echocardiography, training beyond Level II can be achieved either during the standard 3-year fellowship (for those individuals seeking dedicated Level III training focused on echocardiography) or during an additional period of training beyond the standard 3-year fellowship for those desiring advanced echocardiography competency as part of multimodality imaging training. Fellows pursuing this advanced training during the 3-year fellowship will devote all available elective time to echocardiography, precluding acquisition of Level II competency in any other imaging modality. In both pathways, Level III training in echocardiography should take place in laboratories with Level III–trained faculty and with the necessary infrastructure to provide the advanced training experience. Level III training is described here in relatively broad terms to provide context for trainees. The additional exposure and requirements for Level III training will be addressed in a subsequent, separately published Advanced Training Statement.

The numbers of cases, procedures, and experiences recommended are based on published guidelines, competency statements, and the opinions of the members of the writing group. It is assumed that training is directed by appropriately-trained mentors in an ACGME–accredited program and that satisfactory completion of training is documented by the program director. The number and types of encounters and the duration of training required for each level of training are summarized in Section 4 .

2.1

Faculty

The echocardiographic laboratory in which training of cardiovascular fellows is undertaken should be under the direct supervision of a full-time qualified director (or directors) who has achieved Level III training. Participation of additional full- or part-time faculty provides a diversity of experience and is highly desirable. Exposure by the trainee to faculty and sonographers with different strengths and interests ensures a range of experience and a broader base of knowledge.

2.2

Facilities and Equipment

To provide acceptable fellowship training in echocardiography, a laboratory must have equipment capable of providing comprehensive TTE and transesophageal echocardiography (TEE), including M-mode and 2D and 3D imaging, pulsed and continuous-wave Doppler echocardiography, tissue Doppler, stress echocardiography, and color-flow imaging. The laboratory environment should offer a broad range of clinical material. The laboratory should conform to continuing quality improvement guidelines and ideally perform at least 2,000 echocardiographic studies per year to give the fellow an appropriate variety of experience. Accreditation of the laboratory through an organization such as the Intersocietal Accreditation Commission for Echocardiography (IAC Echocardiography) is strongly encouraged. Intraprocedural (including intraoperative) echocardiography and an exposure to adults with structural and congenital heart disease should be available.

A rich and diverse clinical milieu will provide an environment in which the echocardiographic findings can be correlated with other diagnostic data and patient outcomes. Access during echocardiography training to other imaging modalities provides an opportunity to understand the strengths and limitations of echocardiography relative to other techniques. At an early stage, the trainee should be exposed to quality improvement initiatives, structured reporting, process improvement, and appropriate use. For those fellows who plan to be involved in clinical research, formal training in modern research methodology, including biostatistics, clinical trial design, ethics, and grant writing, should be available.

2.1

Faculty

The echocardiographic laboratory in which training of cardiovascular fellows is undertaken should be under the direct supervision of a full-time qualified director (or directors) who has achieved Level III training. Participation of additional full- or part-time faculty provides a diversity of experience and is highly desirable. Exposure by the trainee to faculty and sonographers with different strengths and interests ensures a range of experience and a broader base of knowledge.

2.2

Facilities and Equipment

To provide acceptable fellowship training in echocardiography, a laboratory must have equipment capable of providing comprehensive TTE and transesophageal echocardiography (TEE), including M-mode and 2D and 3D imaging, pulsed and continuous-wave Doppler echocardiography, tissue Doppler, stress echocardiography, and color-flow imaging. The laboratory environment should offer a broad range of clinical material. The laboratory should conform to continuing quality improvement guidelines and ideally perform at least 2,000 echocardiographic studies per year to give the fellow an appropriate variety of experience. Accreditation of the laboratory through an organization such as the Intersocietal Accreditation Commission for Echocardiography (IAC Echocardiography) is strongly encouraged. Intraprocedural (including intraoperative) echocardiography and an exposure to adults with structural and congenital heart disease should be available.

A rich and diverse clinical milieu will provide an environment in which the echocardiographic findings can be correlated with other diagnostic data and patient outcomes. Access during echocardiography training to other imaging modalities provides an opportunity to understand the strengths and limitations of echocardiography relative to other techniques. At an early stage, the trainee should be exposed to quality improvement initiatives, structured reporting, process improvement, and appropriate use. For those fellows who plan to be involved in clinical research, formal training in modern research methodology, including biostatistics, clinical trial design, ethics, and grant writing, should be available.

3.1

Didactic Program

Didactic instruction may occur in a variety of formats, including lectures, conferences, journal clubs, and clinical case conferences. A program of didactic instruction is intended to provide the trainee with an understanding of the basic principles and appropriate clinical application of echocardiography. It should incorporate relevant knowledge of cardiac embryology, anatomy, pathology, and physiology, and integrate clinical information gained from other imaging disciplines, such as cardiovascular computed tomography, cardiovascular magnetic resonance, angiography, and nuclear medicine. The program should also expose trainees to appropriate use criteria for ordering echocardiographic tests. With the increased role of echocardiography in guiding interventional procedures, a specific program of instruction in the intraoperative use of echocardiography and its role in guiding management of structural/arrhythmic heart disease should be available for the advanced trainee.

The precise format for best achieving these educational goals will vary from institution to institution; however, given the increasing clinical application of other imaging modalities within cardiology, it is recommended that a common element of any didactic program include specific multimodality imaging conferences that address the appropriate use of echocardiography in clinical decision making.

3.2

Clinical Experience

Echocardiography plays an important role in the diagnosis and treatment of a wide variety of acquired and congenital cardiac disorders. Accordingly, exposure to the entire spectrum of heart disease in a diverse patient population should be available to the trainee. Although a recommended number of clinical cases to encounter during training is provided (see Section 4.2 ), these criteria merely serve as proxies for clinical exposure. In terms of the overall quality of the educational experience and depth of understanding, the number of echocardiographic studies in which the trainee participates is less important than the range of pathologies encountered and adequacy of supervision and instruction. The criteria described herein are similar to those in other publications on this topic. If the case mix available for the trainee is skewed, additional cases beyond the numbers quoted may be required to ensure appropriate experience.

3.3

Hands-On Experience

The echocardiographic examination is an exceedingly operator-dependent procedure in which it is possible to introduce confounding artifacts or to omit data of diagnostic importance. The echocardiographic examination is interactive, requiring the real-time recognition of specific diagnostic findings to obtain a study that is of clinical benefit. Therefore, fellowship training in echocardiography must emphasize the ability of the trainee to perform a hands-on examination independently with understanding of the results at the time of image acquisition. The trainee should develop sufficient technical skills in using an echocardiographic instrument to answer common clinical questions.

Such training is important not so much to develop true technical expertise as to better understand the diagnostic capabilities and potential pitfalls of the echocardiographic examination. It also helps trainees to learn tomographic cardiac anatomy and integrate planar views into a 3D framework. Highly skilled cardiac sonographers with broad experience in performing echocardiographic examinations are necessary to facilitate this training.

In contrast to transthoracic and stress echocardiography, which are most often performed by sonographers, advanced echocardiographic modalities, such as TEE and 3D echocardiography, require the trainee to acquire technical competency in image acquisition and image presentation. Clinical exposure to a broad range of cardiac pathologies and sufficient hands-on experience with the technology are essential for the advanced trainee to gain the requisite technical competency (see Section 4.2 ).

As part of the hands-on aspect of the echocardiographic training program, experience with HCU devices is desirable. These devices extend the clinical utility of echocardiography by allowing the operator to offer a “visual physical examination” in a manner that can be applied practically in the clinical setting. HCU devices offer capabilities similar to but less robust than their standard echocardiographic counterparts. Their appropriate application nevertheless requires that the operator have a fundamental understanding of echocardiographic principles, cardiac anatomy/physiology, and resultant echocardiographic correlates. Therefore, participation in a didactic echocardiographic educational program and hands-on training with conventional echocardiographic equipment best prepares the cardiovascular fellow to utilize HCU in the clinical setting as an adjunct to physical examination.

4.1

Development and Evaluation of Core Competencies

Training and requirements for echocardiography address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.

Table 1 delineates each of the 6 competency domains, as well as their associated curricular milestones for training in echocardiography. The milestones are categorized into Level I, II, and III training (as previously defined in this document) and indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. Acquisition of Level II skills requires additional training during the standard 3-year cardiovascular fellowship. Level III skills may be attained during the standard 3-year fellowship in a dedicated program focused on advanced cardiac ultrasound imaging or may be acquired during a period of additional training, typically for those fellows seeking multimodality imaging training. The table also describes examples of evaluation tools suitable for assessing competence in each domain.

Table 1

Core competency components and curricular milestones for training in echocardiography

Competency component		Milestones (months)
Medical knowledge		12	24	36	Add
1	Know the physical principles of ultrasound and the instrumentation used to obtain images.	I
2	Know the appropriate indications, including the appropriate use criteria, for: M-mode, 2-dimensional, and 3-dimensional transthoracic echocardiography; Doppler echocardiography and color-flow imaging; transesophageal echocardiography; tissue Doppler and strain imaging; and contrast echocardiography.		I
3	Know the limitations and potential artifacts of the echocardiographic examination.	I
4	Know the standard views included in a comprehensive transthoracic echocardiogram.	I
5	Know the standard views included in a comprehensive transesophageal echocardiogram.		I
6	Know the techniques to quantify cardiac chamber sizes and evaluate left and right ventricular systolic and diastolic function and hemodynamics.			II
7	Know the characteristic findings of cardiomyopathies.		I
8	Know the use of echocardiographic and Doppler data to evaluate native and prosthetic valve function and diseases.			II
9	Know the echocardiographic and Doppler findings of cardiac ischemia and infarction, and the complications of myocardial infarction.		I
10	Know the echocardiographic findings of pericardial disease, pericardial effusion, and pericardial constriction.		II
11	Know the characteristic findings of basic adult congenital heart disease.			II
12	Know the findings of complex/postoperative adult congenital heart disease.			III ∗ †	III ∗
13	Know the techniques to evaluate cardiac masses and suspected endocarditis.		II
14	Know the techniques to evaluate diseases of the aorta.		II
15	Know the techniques to assess pulmonary artery pressure and diseases of the right heart.		II
16	Know the use and characteristic findings in the evaluation of patients with systemic diseases involving the heart.		II
17	Know the indications for, and the echocardiographic findings in, patients with known or suspected cardioembolic events.		II
18	Know key aspects of contrast echocardiography including interpretation, administration techniques, and safety information.			II
19	Understand the principles and applications of 3-dimensional echocardiography.		II
20	Recognize and treat the potential complications of stress, contrast, and transesophageal echocardiography.		II
	Evaluation Tools: conference presentation, direct observation, and in-training examination.

Patient care and procedural skills		12	24	36	Add
1	Skill to perform and interpret a basic transthoracic echocardiographic examination.		I
2	Skill to perform and interpret a comprehensive transthoracic echocardiographic examination.			II
3	Skill to perform and interpret a comprehensive transesophageal echocardiographic examination.			II
4	Skill to recognize pathophysiology, quantify severity of disease, identify associated findings, and recognize artifacts in echocardiography.			II
5	Skill to integrate echocardiographic findings with clinical and other testing results in the evaluation and management of patients.		I
6	Skill to interpret stress echocardiography.			II
7	Skill to incorporate stress hemodynamic information in the management of complex valve disease or hypertrophic cardiomyopathy.			II
8	Skill to utilize echocardiographic techniques during cardiac interventions, including intraoperative transesophageal echocardiography.			III †	III
9	Skill to perform and interpret basic 3-dimensional echocardiography.			II
10	Skill to utilize advanced 3-dimensional echocardiography during guidance of procedures and/or surgery.			III †	III
11	Skill to perform and interpret contrast echocardiographic studies.			II
	Evaluation Tools: direct observation, logbook, and simulation.

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