Chapter 26. Training and Certification in Perioperative Transesophageal Echocardiography

Over the past 25 years, transesophageal echocardiography (TEE) has become an integral part of the care received by patients undergoing heart surgery. The interest in the perioperative application of TEE (PTE) continues to broaden and now includes, to name just a few, liver transplantation, lung transplantation, major vascular surgery, and persistent hemodynamic instability in the operating room. Anesthesiologists have been actively involved with PTE from its inception, and some degree of training in PTE has become an integral, accepted component of all anesthesiology residencies. The program requirements for anesthesiology training state that residents should have “significant experience with … the use of TEE.”1 This chapter reviews the issue of training for anesthesiologists in PTE and discusses the development of certification in this area.

One of the first publications addressing training in PTE came from the Cleveland Clinic Foundation, the largest center for heart surgery in the United States.2 The authors described an extensive training program developed for the cardiac anesthesiologists using TEE during heart surgery at their institution. The training took place over a year and started off with 6 months devoted to full-time training, initially in the echocardiography laboratory and then divided between the lab and the cardiac operating room (OR). The second 6 months consisted of closely supervised intraoperative echocardiography experience integrated with anesthesiology responsibilities. The program included extensive training and experience with transthoracic echocardiography (TTE) as well as TEE. The editorial accompanying this publication thoughtfully supported the importance of training in PTE, but pointed out the impracticality of extended, full-time training for many anesthesiologists, and advocated in favor of an “on the job” approach to training through a mentoring program with an experienced expert in PTE to be available at critical times during the procedure.3 The editorial also put forth the view that training in TTE was not the most efficient way for practitioners exclusively using TEE to be trained. Both approaches have been successfully applied in different ways at various institutions, and many TEE education programs provide a combination of intensive full-time echo lab experience with mentoring in the OR.

Perhaps the most important early document to address training and the use of TEE in the perioperative setting was the seminal Practice Guidelines for Perioperative Transesophageal Echocardiography,4 jointly developed by the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) and published in 1996. It was written by a task force formed in 1993 that was led by Daniel Thys, MD, and consisted of nine anesthesiologists, two cardiologists, and one methodologist who reviewed over 500 publications relevant to PTE. While this document focused primarily on the various indications for TEE in the perioperative setting, it did discuss training and fairly specifically defined the cognitive and technical skills needed for training in PTE at two levels, basic and advanced (Tables 26–1 and 26–2). Basic training was defined as the use of TEE in the customary practice of anesthesiology and included such applications as monitoring for myocardial ischemia, evaluation of ventricular function, and assessment of hemodynamic instability. Advanced training included using the full diagnostic potential of TEE such as quantification of cardiac valve lesions and evaluation of valve repairs and complex congenital heart defects. Subsequent PTE guidelines and certification processes have continued to refer to these cognitive and technical skills.

The next major step in the development of training and certification was the formation in 1995 of the SCA Task Force for Certification in Perioperative Transesophageal Echocardiography. This group was led by Solomon Aronson, MD, and consisted of 10 SCA members with considerable experience and expertise in TEE. Over the next 2 years, this group met regularly and developed what is now called the Examination of Special Competence in Perioperative Echocardiography (PTEeXAM). The PTEeXAM covers perioperative applications of TEE at the advanced level, and is intended primarily for anesthesiologists using TEE during cardiac surgery, although other physicians are eligible and have taken it. Early on, the task force considered whether to create certification processes at both the basic and advanced level, and after much discussion the decision was to address only the advanced level, and defer basic level certification to another time and place. Besides the cognitive and technical skills described for the advanced level in the practice guidelines, the test writers had in mind the level of knowledge in PTE that a candidate would have after completing a 1-year fellowship in cardiothoracic anesthesiology. The SCA worked with the National Board of Medical Examiners in developing the PTEeXAM to assure the quality of the examination and the certification process.

The examination was administered in a pilot form to a group of volunteers at the SCA annual meeting in 1997 in order to assess the quality of the questions and to help establish the level of knowledge, or standard, required to pass the test. The PTEeXAM was then offered for certification to interested physicians at the SCA annual meeting in 1998 and has been given every year since that time. Over 4000 physicians, the vast majority anesthesiologists, have taken it. The same level of knowledge (standard) was used to determine the passing score for the PTEeXAM through 2001 and then, because of a steadily increasing passing rate of well over 80%, a somewhat higher standard was set, essentially raising the bar, in order to keep the PTEeXAM a credible test of advanced knowledge in PTE. This new standard has been used to determine the passing score since 2002. Over the first 4 years the test was given, overall performance was positively related to having 3 or more months of training in echocardiography or performing at least six TEE examinations per week.5

The National Board of Echocardiography (NBE) currently develops and administers the PTEeXAM and certifies individual practitioners in advanced PTE. The origins of the NBE date from 1992, when the American Society of Echocardiography (ASE) formed the ASEeXAM parent committee, which was chaired by Arthur “Ned” Weyman, MD, and was charged with developing a process by which physicians could demonstrate special competence in adult echocardiography. The result was what is now called the Examination of Special Competence in Adult Echocardiography (ASCeXAM), which has been given at the ASE annual meeting since 1995. The ASCeXAM is a general test of knowledge in adult echocardiography including transthoracic and stress echo, and is intended mainly for cardiologists, although other physicians including anesthesiologists are eligible and have taken it. But it was primarily out of concern that the ASCeXAM was not an appropriate measure of knowledge in PTE for most anesthesiologists that the SCA formed the Task Force for Certification in Perioperative TEE, which developed the PTEeXAM. In 1996, in order to deal with potential conflict of interest issues that arose with the ASE certifying practitioners in echocardiography, the ASEeXAM parent committee became an independent corporation called ASEeXAM, Incorporated. In 1998, as a result of negotiations between ASEeXAM, Inc and the SCA, ASEeXAM, Inc took on writing and administration of the PTEeXAM and changed its name to the NBE.

Anesthesiologists are well represented at the NBE. Three members of the NBE Board of Directors must belong to the SCA. It takes a supermajority to change the NBE bylaws, so that at least one anesthesiologist must support any future bylaws changes. In fact, there have been no significantly contentious issues dividing the cardiologists and anesthesiologists within the NBE. The cardiology members have been very accommodating and supportive of the efforts of the anesthesiologists to develop a credible, fair process by which anesthesiologists can demonstrate their competence in advanced PTE. As a matter of fact, an anesthesiologist, Daniel Thys, has served as president of the NBE.

After 1998, the NBE was writing and administering two examinations in echocardiography: the ASCeXAM primarily for cardiologists and the PTEeXAM primarily for anesthesiologists. But the certificates issued could only attest to the fact that someone had passed the test, not that they had demonstrated competence in echocardiography. Board certification in a medical specialty typically requires individuals to demonstrate competency by completing a specific training program and then passing a board examination. In addition, for some period of time newly created specialties usually allow current practitioners to substitute practice experience for training. In 2001, the NBE initiated a certification process based on training guidelines for echocardiography published in the cardiology literature by which physicians could, by passing the ASCeXAM and providing documentation of specified training and experience, become certified as Diplomates of the NBE in adult echocardiography. The NBE began using the term “testamur” (ie, one who has passed a test) to refer to those who had passed an examination but had not become certified by submitting documentation of the required training or experience.

In order for PTEeXAM certification to remain credible compared to ASCeXAM certification, a similar process of submitting documentation of training or experience had to be developed for the PTEeXAM. However, there were no published training guidelines in PTE for the NBE to refer to in developing advanced PTE certification. Previously published guidelines for training in TEE were intended for cardiologist echocardiographers and recommended at least 6 months of training in transthoracic echocardiography as a prerequisite to TEE.6 Consequently, in 2000 the ASE and SCA formed the Task Force for Training Guidelines in Perioperative Echocardiography, chaired by Michael Cahalan, MD, to formulate training guidelines and, by the same token, facilitate the development of a certification process in advanced PTE. The task force consisted of the chair, four cardiologists, and four anesthesiologists with experience and expertise in PTE. This group produced several drafts before developing a set of acceptable guidelines that were subsequently adopted by both the SCA and ASE Boards of Directors.

The guidelines for training in perioperative echocardiography made recommendations for training in both basic and advanced PTE as described in the 1996 ASA/ SCA Practice Guidelines in PTE. For basic training, the task force recommended study of 150 complete TEE examinations under appropriate supervision, including the full spectrum of commonly encountered perioperative diagnoses and at least 50 comprehensive intraoperative TEE examinations personally performed, interpreted, and reported by the trainee. For advanced-level training the recommendation was the study of 300 complete examinations under appropriate supervision, including a wide spectrum of cardiac diagnoses and at least 150 comprehensive intraoperative TEE examinations personally performed, interpreted, and reported by the trainee. The guidelines recognize that physicians in practice may be able to acquire the requisite knowledge and skills without enrolling in a formal, supervised training program, as long as they can document their experience in detail and be able to demonstrate its equivalence to the supervised training guidelines.

The guidelines were published in 20027,8 and adopted by the NBE as requirements for training and experience for advanced PTE certification. It is important to note that the training requirements for certification were not arbitrarily developed by the NBE, but came from a document that was developed and adopted by the SCA and ASE through an insightful and extensive process involving several iterations of feedback and modification. The NBE issued applications for certification in advanced PTE in late 2003 and began certifying individual practitioners in February 2004. As of February 2009 over 1200 physicians have been certified as Diplomates of the NBE in PTE; all but a few are anesthesiologists. Because NBE certification is a requirement, the advanced PTE certification process has made it possible for many anesthesiologists to become Fellows of the American Society of Echocardiography (FASE).

There are five requirements for certification by the NBE in advanced PTE. The applicant must have:

1. Passed the advanced PTEeXAM within 10 years

2. A current, unrestricted license to practice medicine

3. Board certification in a medical specialty recognized by the American Board of Medical Specialties (ABMS)

4. Training or experience in the perioperative care of patients with cardiovascular disease

5. Training or experience in advanced perioperative TEE

Requirement 4—training or experience in the perioperative care of patients with cardiovascular disease—may be accomplished through one of two pathways: the supervised training pathway or the practice experience pathway. The supervised training pathway requires completion of at least 1 year of fellowship training in cardiovascular disease after core residency. This most commonly is a cardiothoracic anesthesiology fellowship, but could be fellowship training in cardiology, critical care medicine, or thoracic surgery as long as there is extensive perioperative experience. The practice experience pathway specifies that the applicant must have at least 24 months of experience in perioperative care of patients with cardiovascular disease, including at least 150 patients in each of the 2 years prior to application for certification. These patients do not necessarily have to be undergoing heart surgery, but must have significant cardiovascular disease.

Similarly, requirement 5, training or experience in PTE, may be fulfilled through a supervised training or a practice experience pathway. For supervised PTE training, applicants must study 300 complete perioperative TEE examinations under appropriate supervision. These examinations must include a wide spectrum of cardiac diagnoses and at least 150 comprehensive intraoperative TEE examinations personally performed, interpreted, and reported by the applicant. With the practice experience pathway applicants must perform and interpret at least 300 perioperative transesophageal echocardiograms within 4 consecutive years immediately preceding application with no less than 50 in any year in which any of the 300 echocardiograms were performed. At least 150 of the 300 TEE examinations must be intraoperative. The practice experience pathway also requires at least 50 hours of American Medical Association (AMA) category 1 level continuing medical education devoted to echocardiography be obtained within 4 years of application. For applicants completing their core residency training (usually in anesthesiology) after June 30, 2009, requirement 5 must be fulfilled through the supervised training pathway; the practice experience pathway will remain open indefinitely for those who have finished their core residency on or before that date. Applications from candidates outside of North America are considered based on the equivalency of training compared to the United States and Canada.

All certificates issued by the NBE expire after 10 years, so recertification processes for both the ASCeXAM and PTEeXAM have been developed. The first advanced PTEeXAM certificates were issued in 1998, and the recertification exam for advanced PTE (RePTE) was given for the first time in 2007. Candidates for recertification may take the RePTE the year their certificate expires, the year before, or the year after. Those who fail to recertify by the year after expiration of their certificate will have to retake and pass the PTEeXAM and fulfill the requirements for initial certification again in order to regain advanced PTE certification. The RePTE exam has been a subset of questions from the PTEeXAM that are focused on clinical issues. There are four requirements for recertification by the NBE in advanced PTE. The applicant must have:

1. Passed the RePTE exam before the 1-year anniversary of the expiration of their PTEeXam certificate

2. A current, unrestricted license to practice medicine

3. Performed and interpreted at least 50 perioperative TEEs per year in 2 of the 3 years immediately preceding application

4. At least 15 hours of AMA category 1 continuing medical education devoted to echocardiography obtained during the 3 years immediately preceding application

Another important advance made by the NBE for all of its examinations is the move from paper testing forms to computer-based testing. As of 2009, candidates will take an NBE examination by going to a local testing center on a specified date.

In 2007, the Accreditation Council for Graduate Medical Education (ACGME) began accrediting adult cardiothoracic anesthesiology (ACTA) fellowships, culminating an almost 10-year process of application and reapplication pursued persistently by the SCA. These fellowships last 1 year and require successful completion of an accredited anesthesiology residency as a prerequisite. In developing the ACTA fellowship program requirements, the anesthesiology Residency Review Committee of the ACGME essentially adopted the ASE/SCA Guidelines for Training in Perioperative Echocardiography recommendations for advanced PTE.9 As a result, trainees completing an accredited ACTA fellowship are eligible for NBE certification in advanced PTE, provided they pass the PTEeXAM. This has afforded an objective measure and accomplishment by which those completing ACTA fellowships can validate their subspecialty training, in lieu of subspecialty certification in adult cardiothoracic anesthesiology. Now that there is accredited subspecialty training in ACTA, the issue of whether or not to provide subspecialty board certification in this area is due to be addressed by the American Board of Anesthesiology around 2012. It seems certain that any such certification process would have to include an assessment of knowledge of advanced PTE.

In 2006, the ASA House of Delegates passed a resolution directing the ASA to create a certification process for PTE at the basic level. A primary motivation for this was the belief that many anesthesiologists regularly use TEE in their practice at a frequency insufficient to obtain advanced PTE certification. The ASA approached the NBE regarding this issue, and the two organizations have developed a basic PTE certification process that was launched in 2009. The scope of practice for basic PTE is defined by the ASA and NBE as follows:

The application of a basic perioperative TEE examination is limited to non-diagnostic monitoring within the customary practice of anesthesiology. Because the goal of training in basic PTE is focused on intraoperative monitoring rather than specific diagnosis, except in emergent situations, diagnoses requiring intraoperative cardiac surgical intervention or post-operative medical/surgical management must be confirmed by an individual with advanced skills in TEE or by an independent diagnostic technique.

Besides the cognitive and technical skills described for basic PTE in the practice guidelines, the level of knowledge intended for practitioners of basic PTE would enable them to use TEE as a hemodynamic and cardiac monitor during general anesthesia, but not direct surgical decisions during heart surgery. The basic TEE exam consists of the midesophageal four-chamber, two-chamber, long-axis, and right ventricular (RV) inflow-outflow views; the transgastric mid short-axis view; and views of the thoracic aorta from the diaphragm to the arch, with views of the valves repeated using color-flow Doppler. There is at least one study suggesting that a limited, basic TEE examination can acquire most of the information obtained in a comprehensive exam.10

The NBE is developing an examination assessing knowledge in basic PTE, which is scheduled to be given in the fall of 2010 (www.echoboards.org). Until the basic PTEeXAM is available, candidates may fulfill the examination requirement for basic PTE certification by passing the advanced PTEeXAM. There are four requirements for certification by the NBE in basic PTE. The applicant must have:

1. Passed the basic or advanced PTEeXAM within 10 years

2. A current, unrestricted license to practice medicine

3. Board certification in anesthesiology

4. Training or experience in basic perioperative TEE

There are three pathways offered by the NBE to fulfill the echocardiography training requirement for basic PTE certification that are based on the ASE/SCA Guidelines for Training in Perioperative Echocardiography: the supervised training pathway, the practice experience pathway, and the extended continuing medical education (CME) pathway. For the supervised pathway, applicants must study at least 150 basic perioperative TEE examinations under appropriate supervision. Of these, the applicant must personally perform and interpret at least 50 basic intraoperative TEE examinations. Supervised training in basic perioperative TEE is limited to accredited anesthesiology residency programs, and must be accomplished within a 4-year period of time or less. For the practice experience pathway, applicants must perform and interpret at least 150 basic intraoperative TEE examinations within 4 consecutive years with no less than 25 in any year. In addition, applicants must obtain at least 40 hours of AMA category 1 continuing medical education devoted to perioperative TEE obtained within 4 years. The practice experience pathway will not be available to those completing tier anesthesiology residency training after June 30, 2016. For the extended CME pathway, applicants must have personally performed and interpreted at least 50 basic intraoperative TEE examinations within 2 years of the application with at least 25 within 1 year of the application. Applicants must also study, personally interpret, and subsequently review, either under direct supervision or in an electronic format acceptable to the NBE and ASA, at least 100 basic perioperative TEEs from a banked source. This education program must be accredited for at least 30 AMA category 1 CME hours. Applicants must also have at least 10 additional hours of AMA category 1 CME devoted to perioperative TEE within 2 years.

Accreditation in adult TEE is a joint initiative of the European Association of Echocardiography and the European Association of Cardiothoracic Anesthesiologists (http://www.escardio.org/communities/EAE/accreditation/TEE/Pages/aims.aspx) that was launched in 2005. Currently, specific certification in PTE is not offered. The accreditation process consists of two parts: (a) written exam of multiple-choice questions (single best answer) with 50 questions related to cases displayed on a screen and 100 questions related to theory, and (b) practical assessment accomplished by submitting a case log of 125 exams performed within a 12-month period from which 15 cases are chosen randomly and reviewed by graders. Accreditation will last only for 5 years and a re-accreditation process is currently under development.

There is no formal process for accreditation in Australia, but the Australian and New Zealand College of Anaesthetists (ANZCA) has issued guidelines for the training and practice of perioperative TEE (http://www.anzca.edu.au/resources/professional-documents/professional-standards/pdfs/PS46.pdf/). The period of training is defined as the equivalent of 50 days full-time over a minimum period of 10 weeks to a maximum of 2 years. During the period of training, the trainee is expected to perform and report 50 complete TEE examinations under supervision, 50 unsupervised examinations, and at least 100 additional supervised reviews. Ongoing competence requires performance of at least 30 examinations and reviews of at least 50 recorded exams every year. Completion of the PTEeXAM or the Postgraduate Diploma in Perioperative and Critical Care Echocardiography from the University of Melbourne is also strongly recommended. Practitioners of TEE should additionally satisfy the requirements of the Australian Society of Ultrasound in Medicine (Intercollegiate Consensus Statement 1995) and the Cardiac Society of Australia and New Zealand for training in echocardiography. The latter society recommends intraoperative training to consist of 150 studies in basic monitoring, of which 50 have been personally performed, and 150 advanced (valve) studies, of which 50 have been personally performed.

Now that training and certification requirements are clearly defined, it seems likely that some anesthesiology residencies will begin to offer basic PTE training to at least some of their residents. If this trend does in fact develop, it seems possible that more and more residencies would provide basic PTE training in order to remain competitive and attract the best residents. And it's not entirely impossible to envision a day—probably many years from now, despite the current lack of sufficient equipment, clinical material, and expertise at many if not most training programs—when all anesthesiology residents are trained in basic PTE and every certified anesthesiologist is competent to use TEE as a hemodynamic and cardiac monitor during general anesthesia.