Since its introduction into the perioperative arena,1 transesophageal echocardiography (TEE) has become an integral part of the care received by patients undergoing heart surgery. The use of TEE in surgical care continues to expand to other areas, such as liver transplantation, lung transplantation, major vascular surgery, and persistent hemodynamic instability in the operating room. Evolving areas such as transcatheter treatment of structural heart disease involve critical procedural guidance using TEE, which may be performed by anesthesiologists or cardiologists depending on institutional preference. Anesthesiologists have been actively involved with perioperative TEE (PTE) since its inception, and some degree of training in PTE has become an integral, accepted component of all anesthesiology residencies in the United States. The American Board of Anesthesiology includes an expectation of echocardiographic recognition of normal cardiac anatomy using TEE in their primary certification content outline under “advanced topics.”2 In addition, the Accreditation Council for Graduate Medical Education (ACGME) includes the placement and use of TEE as a competency requirement for any accredited anesthesiology residency program.3 For trainees in a cardiology program, the American College of Cardiology defines the overall requirements for training in the Core Cardiology Training Statement (COCATS), currently in version 4, with requirements in echocardiography described by task force 5.4 This chapter reviews the training and certification requirements for competence in PTE with a brief historical context and an emphasis on the current status in the United States.
HISTORY OF TRAINING AND CERTIFICATION IN THE UNITED STATES
Development of a Training Program
A few prominent academic institutions in the United States developed their own training programs in PTE, recognizing the need for specialized training. One of the first such descriptions came from the Cleveland Clinic, Cleveland, OH.5 They described their training program focused on cardiac anesthesiologists in collaboration with cardiologists. The training was for one year and blended experience in the echocardiography laboratory and the operating room (OR) in a supervised environment. The program included training and experience with transthoracic echocardiography (TTE) as well as TEE, the former being considered essential for introducing core concepts in ultrasound, to which there was little exposure during anesthesia training. However, the impracticality of extended, full-time training for many anesthesiologists was recognized, and an “on the job” approach to training through a mentoring program with an expert in PTE was advocated.6
In 1996, the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) led by Daniel Thys, MD, jointly published the first Practice Guidelines for Perioperative Transesophageal Echocardiography.7 While this document focused primarily on the various indications for TEE in the perioperative setting, it also discussed training and specifically defined the cognitive and technical skills needed for training in PTE at basic and advanced levels. Subsequent updates of the PTE guidelines and certification processes have continued to refer to these cognitive and technical skills.
Development of the PTEeXAM