The American College of Cardiology, American Heart Association, and American Society of Echocardiography (ACC/AHA/ASE) have released an updated advanced training joint statement on echocardiography for hospital medical staff, clinicians, and other healthcare providers. The full report, describing the core competencies required of subsubspecialists in echocardiography, can be found in the Journal of the American College of Cardiology.
Members from the ACC, AHA, and ASE who performed ≥1 echocardiography-related role, including echocardiography laboratory directors, cardiovascular training program directors, and scientists who perform echocardiography research, were included in the statement’s writing committee. The statement was designed to reinforce the ultimate goal of the original 1995 ACC recommendations for training in adult cardiology, which was to provide a trainee with the “professional skill set to be able to evaluate, diagnose, and treat patients with acute and chronic cardiovascular conditions,” with a specific focus on echocardiography.
According to the statement, the main echocardiography training components include a didactic program, clinical experience, hands-on procedural experience, diagnosis and management of emergencies and complications, diagnosis and management of rare clinical conditions and syndromes, and research and scholarly activity.
A didactic program can be carried out using lectures, online modules, journal clubs, clinical case presentations, research conferences, and simulator-based training. Relevant content in these programs should incorporate education on the clinical application of echocardiography, should provide advanced medical knowledge, and should provide education on patient care relevant to the required competencies.
For clinical experience, trainees should gain “exposure to the entire spectrum of heart diseases in diverse patient populations” combined with echocardiography practice. In addition, the writing committee cited exposure to echocardiographic evaluation of congenital heart disease to be an essential component of a well-rounded training program involving clinical experience.
Hands-on procedural experience, which involves an interactive examination performed by the trainee independently, is another crucial training component developed during level II training. During a hands-on approach, the goal is to help the trainee develop sufficient technical skills for echocardiography use that will help answer clinical questions during fellowship training. Hands-on procedural training helps the trainee learn about tomographic cardiac anatomy in varying cardiac diseases.
A training program should also encompass educational elements designed to help trainees handle an echocardiography instrument in an emergency situation. These situations would involve using the instrument for rapid diagnosis in patients whose vital signs are not stable and who have life-threatening diseases.
During level III training, trainees should receive education on echocardiographic findings for less common conditions associated with the heart. This may include gaining understanding of complex and postoperative findings in congenital heart disease. The training phase should also help clinicians develop skills for careers that involve research and education. To accomplish this goal, the trainee should also work with faculty in translational, imaging science, and/or clinical research.
A total of 6 domains are used to organize advanced training competencies: Medical Knowledge, Patient Care and Procedural Skill, Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills. In the statement, the ACC/AHA/ASE writing committee provided several competency components for medical knowledge, including knowledge regarding physics, hemodynamics, ventricular disease, atrial anatomy and physiology, pulmonary hypertension, valvular disease, pericardial disease, stress testing, aorta diseases, and research.
Procedural and technical experience of any training program, according to the statement, is defined by the quality as well as by the volume of training. For level III general training, the task force reports that training should be flexible and allow trainees “to pursue a program that best fits their long-term goals and career focus.” Level III training should involve gaining expertise and skill in advanced echocardiographic imaging methods, including 3-dimensional imaging, strain, and contrast imaging. Additionally, the program should give “a structured educational program that enables the trainee to best apply these methods in the treatment of specialized patient populations.”
Training programs should also incorporate educational protocols on special ultrasound procedures for the diagnosis, management, and guidance of invasive procedures and surgeries. Specific recommendations were provided for transesophageal echocardiography, with a lower-volume setting suggested for training programs.
Trainees should understand the use of transesophageal echocardiography in outpatient and in-hospital settings. For 3-dimensional echocardiography, recommendations were made for level II and level III training. Additional training recommendations were created for contrast echocardiography, strain echocardiography and myocardial mechanics, stress echocardiography, and echocardiography during interventions.
Finally, the committee wrote that procedural skills and clinical judgment for every trainee should be evaluated regularly. “The program director is responsible for confirming experience and competence and reviewing the overall progress of individual trainees to ensure achievement of selected training milestones and identify areas in which additional focused training may be required,” the committee wrote. “On a periodic basis throughout the course of training, the program director should review the trainee’s case logbook to ensure the adequacy of the trainee’s exposure to a broad spectrum of cardiac pathology and the trainee’s experience in applying advanced imaging echocardiographic techniques to evaluate same.”
Wiegers SE, Ryan T, Arrighi JA, et al. 2019 ACC/AHA/ASE advanced training statement on echocardiography[published online January 19, 2019]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2019.02.003