30 The past several decades have seen a surge in ultrasonography use in the field of anesthesiology. 1 Anesthesiologists have increasingly used ultrasound for central venous cannulation and peripheral nerve blockade, which has resulted in increased efficacy and patient safety.2,3 Use of echocardiography has grown in both the operating room (OR) and intensive care unit (ICU).4,5 Transesophageal echocardiography (TEE) has transitioned from an adjunctive tool to a required piece of equipment, with utilization by anesthesiologists for perioperative management, and by surgeons for appropriate planning and postprocedure evaluation. 6 Indeed, TEE has become a standard of care for certain cardiac surgical procedures, such as mitral valve repair and transcatheter aortic valve replacement. With increasing use of TEE in the perioperative period, the certification process was developed to ensure that practitioners utilizing this tool are appropriately competent to adequately perform an examination and interpret the findings. In 1993, the American Society of Anesthesiology (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) created an Ad Hoc Task Force on Practice Parameters for Transesophageal Echocardiography to establish guidelines for the use of TEE in the OR. 7 Beyond recommendations for intraoperative use, the task force also evaluated training guidelines. 8 Previously, the establishment of guidelines for TEE had been developed primarily for cardiologists, while acknowledging the utility of TEE for anesthesiologists regarding intraoperative decision making. 9 The ASA/SCA task force acknowledged that many anesthesiologists used TEE primarily for monitoring and treatment decisions, whereas others used it for diagnostic purposes. It was also recognized that the training and knowledge required for certification varied across institutions. 8 As a result, the American Society of Echocardiography (ASE) and SCA created a task force to establish requisite knowledge and training requirements for individuals seeking to become certified in perioperative TEE. 7 The initial recommendation was published jointly in 1999 by the SCA and ASE (and updated in 2002) regarding the performance of a comprehensive intraoperative TEE.10,11 The ASE first developed and administered formal testing of echocardiography for cardiologists (although open to other specialties) in 1996 as the Examination of Special Competence in Adult Echocardiography (ASEeXAM). The SCA independently administered a test of perioperative TEE knowledge in 1998, referred to as the PTExAM. With establishment of the National Board of Echocardiography (NBE) through a joint venture between the SCA and ASE, a governing body for testing and certification in echocardiography was formed. 7 Guidelines were established for certification of required knowledge and experience. The first physician TEE certification by the NBE occurred in 2004, with certification lasting for 10 years from the date the knowledge test was passed. A recertification examination (and requirements for qualification) was subsequently developed for those individuals wishing to remain certified in perioperative TEE. Recertification must be undertaken within 8 to 10 years of initial certification and mandates documentation of continued experience in performing and interpreting perioperative TEE examinations. As of mid 2013, 3310 clinicians currently have Testamur status after having passed the Advanced PTE examination, and 1897 have completed the formal certification process and become Diplomates. Of the latter, 539 have been recertified after 10 years of using TEE in clinical practice (written communication, May 27, 2013, National Board of Echocardiography). According to the NBE, the stated purpose of TEE certification is fivefold. 12 • Establish domain of the practice of echocardiography for the purpose of certification. • Assess the level of knowledge demonstrated by a licensed physician practitioner of echocardiography in a valid manner. • Enhance the quality of echocardiography and individual professional growth in echocardiography. • Formally recognize individuals who satisfy the requirements set by the NBE. • Serve the public by encouraging quality patient care in the practice of echocardiography. According to the NBE, the defined scope of practice for individuals requesting certification in basic TEE is limited to nondiagnostic monitoring within the customary practice of anesthesiology. Although diagnoses may be made in emergent situations, findings should be confirmed by an individual with advanced skills in TEE or by other appropriate methods. The areas of anesthesia practice in which TEE is used extensively for treatment decisions include liver transplantation, critical care, and noncardiac surgery in selected operative patients.13–17 Box 30-1 lists NBE certification requirements. 12 BOX 30-1 PERIOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY CERTIFICATION REQUIREMENTS FROM THE NATIONAL BOARD OF ECHOCARDIOGRAPHY Basic PTE Certification Requirements • Current unrestricted license to practice medicine • Board certification in anesthesiology • Training in basic perioperative TEE (two pathways are available) • Supervised training pathway: • 150 basic perioperative TEE examinations, of which: • 50 basic intraoperative TEE examinations must be personally performed • Examinations not personally performed must be reviewed at the institution where the applicant has done his/her 50 personally performed examinations • Supervised training must be obtained from an ACGME-accredited or other national agency-accredited anesthesiology residency program, and must be accomplished within a 4-year period of time or less • Practice experience pathway: • At least 150 basic intraoperative TEE examinations within 4 consecutive years immediately preceding application, with no less than 25 in any given year • At least 40 hours of AMA category 1 CME devoted to perioperative TEE during time the physician is acquiring the requisite clinical experience in TEE Advanced PTE Certification Requirements • Current unrestricted license to practice medicine • Board certification in an American Board of Medical Specialties, Advisory Board for Osteopathic Specialties, the American Association of Physician Specialists, or Royal College of Physicians and Surgeons of Canada • Passing the Advanced PTEeXAM • Training/experience in perioperative care of surgical patients with cardiovascular disease • Copy of certificate of successful completion of fellowship training (minimum 12 months) dedicated to the perioperative care of surgical patients with cardiovascular disease • Specific training in advanced TEE under supervision with 300 completed examinations, of which: • Practice experience pathway: • Minimum 24 months of clinical experience dedicated to perioperative care of surgical patients with cardiovascular disease, including care personally delivered by applicant to a minimum of 150 patients with cardiovascular disease per year in each of the 2 years preceding application. This pathway is only valid for those who completed an ACGME residency prior to June 30, 2009. • Minimum of 300 comprehensive perioperative TEEs within 4 consecutive years, with no less than 50 in any year, which must occur within 10 years preceding the application
Training and Certification for Transesophageal Echocardiography
Historical Perspective in the United States
Certification
Basic Certification
