2019 ACC/AHA/ASE advanced training statement on echocardiography (revision of the 2003 ACC/AHA clinical competence statement on echocardiography)

James A. Arrighi, MD, FACC, Chair Lisa A. Mendes, MD, FACC, Co-Chair Jesse E. Adams III, MD, FACC John E. Brush Jr, MD, FACC# G. William Dec Jr, MD, FACC Ali Denktas, MD, FACC Susan Fernandes, LPD, PA-C Rosario Freeman, MD, MS, FACC# Rebecca T. Hahn, MD, FACC Jonathan L. Halperin, MD, FACC** Susan D. Housholder-Hughes, RN, DNP, ACNS-BC, ANP-BC, FACC Sadiya S. Khan, MD, FACC Kyle W. Klarich, MD, FACC C. Huie Lin, MD, PhD, FACC Joseph E. Marine, MD, FACC John A. McPherson, MD, FACC# Khusrow Niazi, MBBS, FACC Thomas Ryan, MD, FACC Michael A. Solomon, MD, FACC Robert L. Spicer, MD, FACC Marty Tam, MD Andrew Wang, MD, FACC, FAHA Gaby Weissman, MD, FACC Howard H. Weitz, MD, MACP, FACC Eric S. Williams, MD, MACC†† #Former Competency Management Committee member; member during this writing effort. **Former Competency Management Committee co-chair; co-chair during this writing effort ††Former Competency Management Committee chair; chair during this writing effort Since publication of its first Core Cardiovascular Training Statement (COCATS) in 1995, the American College of Cardiology (ACC) has defined the knowledge, experiences, skills, and behaviors expected of clinical cardiologists. Subsequent revisions have moved toward competency (outcomes)-based training based on the six-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and endorsed by the American Board of Internal Medicine (ABIM). The ACC has taken a similar approach to describe the aligned general cardiology lifelong learning competencies that practicing cardiologists are expected to maintain. Many hospital systems now use the six-domain structure as part of medical staff privileging, peer review, and professional competence assessments. Whereas COCATS and the associated Lifelong Learning Competencies for General Cardiologists focus on general clinical cardiology, ACC Advanced Training and associated Lifelong Learning Statements define selected competencies beyond those expected of all cardiologists and that typically require training beyond a standard 3-year cardiovascular disease fellowship. This includes, but is not limited to, those disciplines for which there is an ABIM sub-subspecialty certification. The Advanced Training Statements describe key experiences and outcomes necessary to acquire skills in a defined sub-subspecialty area of cardiology in a structured training program. These are supplemented by Lifelong Learning Statements that address the commitment to sustaining and enriching competency over the span of a career. The ACC Competency Management Committee (CMC) oversees the development and periodic revision of the cardiovascular training and competency statements. A key feature of competency-based training and performance is an outcome-based evaluation system. Although specific areas of training may require a minimum number of procedures or duration of training to ensure adequate exposure to the range of clinical disorders, the objective assessment of proficiency and outcomes demonstrates the achievement of competency. Evaluation tools include examinations, direct observation, procedure logbooks, simulation, conference presentations, and multisource (360°) evaluations. For practicing physicians, these tools also include professional society registry or hospital quality data, peer review processes, and patient satisfaction surveys. A second feature of competency-based training is recognition that learners gain competency at different rates. For multiyear training programs, assessment of representative curricular milestones during training can identify learners or areas that require additional focused attention. The recommendations in ACC cardiovascular training statements are based on available evidence and, where evidence is lacking, reflect expert opinion. The writing committees are broad-based, and typically include early-, mid-, and later-career specialists, general cardiology and sub-subspecialty training directors, practicing cardiologists, people working in institutions of various sizes and in diverse practice settings across the United States, and nonphysician members of the cardiovascular care team. All documents undergo a rigorous process of peer review and public comment. Recommendations are intended to guide the assessment of competence of cardiovascular care providers beginning independent practice as well as those undergoing periodic review to ensure that competence is maintained. This Advanced Training Statement addresses the competencies required of sub-subspecialists in adult echocardiography and complements the training in echocardiography required of all trainees during the standard 3-year general cardiovascular fellowship. The statement focuses on the core competencies reasonably expected of all individuals trained at this level. Furthermore, the statement identifies selected competencies of Level III echocardiographers that go beyond core expectations that may be achieved by some advanced trainees either during formal fellowship training or through subsequent training experiences. This document provides examples of appropriate measures for assessing competence in the context of training. The work of the writing committee was supported exclusively by the ACC without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential and attended only by committee members. To avoid actual, potential, or perceived conflict of interest resulting from relationships with industry (RWI) or relationships with other entities held by writing committee members or peer reviewers of the document, individuals were required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. The ACC Competency Management Committee reviewed these disclosures to identify products (marketed or under development) pertinent to the document topic. Based on this information, the writing committee was selected to ensure that the Chair and a majority of members had no relevant RWI. Authors with relevant RWI were not permitted to draft initial text or vote on recommendations or curricular requirements to which their RWI might apply. RWI was reviewed at the start of all meetings and conference calls and updated as changes occurred. Relevant RWI for authors is disclosed in Appendix 1. To ensure transparency, comprehensive RWI for authors, including RWI not pertinent to this document, is posted online, https://www.acc.org/~/media/F63C7730B1B34BA984D0ED3EDE5252A8.pdf. Employment information and affiliations of the peer reviewers are shown in Appendix 2. There are no RWI restrictions for participation in peer review, in the interest of encouraging comments from a variety of constituencies to ensure that a broad range of viewpoints inform final document content. Reviewers are required, however, to disclose all healthcare-related RWI and other entities, and their disclosure information is posted online, https://www.acc.org/~/media/0E3499478B1A475CA5479C56DB05B966.pdf. Disclosure information for the ACC Competency Management Committee is available online, https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces and the ACC disclosure policy for document development is posted online, https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy. James A. Arrighi, MD, FACC. Chair, ACC Competency Management Committee. Lisa A. Mendes, MD, FACC. Co-Chair, ACC Competency Management Committee. The writing committee consisted of a broad range of members representing ACC, the American Heart Association (AHA), the American Society of Echocardiography (ASE), the American Thoracic Society, the Society of Cardiovascular Anesthesiologists, the Society for Cardiovascular Angiography and Interventions, and the Society of Critical Care Medicine, identified because they perform ≥1 of the following roles: cardiovascular training program directors; Level III echocardiography-trained program directors; echocardiography laboratory directors; experts at early, mid-, and later-career stages; cardiovascular sonographers; scientists who do echocardiography research; multimodality imagers; general cardiologists; Level III trained echocardiography specialists representing both the academic and community-based practice settings as well as small, medium, and large institutions; specialists in all aspects of echocardiography, including interventional, mechanical circulatory support, cardiac resynchronization therapy, ventricular assist devices, and pulmonary arterial hypertension; specialists in cardiac anesthesiology, interventional cardiology, and critical care medicine; physicians experienced in training and working with the ACGME/Residency Review Committee, the ABIM Cardiovascular Board and Competency Committee, and the National Board of Echocardiography (NBE); and physicians experienced in defining and applying training standards according to the six general competency domains promulgated by the ACGME and the American Board of Medical Specialties and endorsed by the ABIM. This writing committee met the College's disclosure requirements for relationships with industry as described in the Preamble. The writing committee chairs, CMC chairs, and CMC liaison convened to plan the writing effort, selected authors on the basis of the criteria specified in Section 1.1.1, and drafted the preliminary competency table for writing committee feedback. The writing committee convened by conference call and email to finalize the document outline, develop the initial draft, revise the draft on the basis of committee feedback, and ultimately approve the document for external peer review. The document was reviewed by 17 official representatives from the ACC, AHA, ASE, American Thoracic Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Critical Care Medicine, as well as by 39 additional content reviewers, including both cardiovascular and imaging training program directors. The list of peer reviewers, employment information, and affiliations for the review process are included in Appendix 2. The document was simultaneously posted for public comment from May 14, 2018 to May 24, 2018, resulting in comments from nine Level II and Level III echocardiographers from various academic institutions, including representation from cardiovascular and imaging training program directors and echocardiographers in early, mid- and later-career stages. A total of 625 comments were submitted on the document. All comments were reviewed and addressed by the writing committee. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. Both the writing committee and the ACC Competency Management Committee approved the final document to be sent for organizational approval. The ACC, AHA, and ASE approved the document for publication with endorsement from the American Thoracic Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Critical Care Medicine. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication. The original 1995 American College of Cardiology recommendations for training in adult cardiology evolved from a core cardiology training symposium.1 After several iterations, COCATS 42 focuses on trainee outcomes that require delineation of specific components of competency within the subspecialty, definition of the tools necessary to assess training, and establishment of milestones documenting the trainee's progression toward independent practice. Ultimately, the goal is for the trainee to develop the professional skill set to be able to evaluate, diagnose, and treat patients with acute and chronic cardiovascular conditions. Each COCATS 4 document includes individual Task Force reports that address subspecialty areas in cardiology, each of which is an important component in training a fellow in cardiovascular disease. The Task Force 5 report of that document addresses training in echocardiography3 and updates previous standards for general cardiovascular training for fellows enrolled in cardiovascular fellowship programs. It addresses faculty, facilities, and equipment. It also addresses training components, including didactic, clinical, and hands-on experience, and the number of procedures and duration of training. However, the COCATS 4 Task Force 5 report did not provide detailed guidelines for Level III echocardiography training or competencies. In contrast to COCATS, this document focuses on training requirements for cardiology fellows seeking Level III training in echocardiography. For training standards related to pediatric echocardiography, readers should refer to the SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs Task Force 2: Pediatric Cardiology Fellowship Training in Noninvasive Cardiac Imaging.4 Echocardiography is essential to the practice of cardiology. It is the most widely used and readily available imaging technique for assessing cardiovascular anatomy and function. Clinical application of ultrasound encompasses M-mode, two-dimensional (2D), three-dimensional (3D), pulsed, tissue, continuous wave, and color-flow Doppler imaging. Echocardiography provides diagnostic and prognostic information on cardiovascular anatomy, function, hemodynamic variables, and flow disturbances. Moreover, these cardiovascular parameters can be assessed at rest, as well as during conditions of increased hemodynamic demand such as exercise. Advanced applications of echocardiography, including 3D imaging, strain imaging, and use of ultrasound enhancing agents (also known as "echo contrast agents") to improve left ventricular endocardial definition and to assess perfusion, as well as the use of real-time imaging to guide invasive procedures, have all become important in the clinical care of patients. All cardiologists should have a basic understanding of echocardiographic techniques—their strengths, limitations, and appropriate use. Although it is expected that most, if not all, fellows will achieve Level II competency in echocardiography during their 3 years of general cardiology training, this document describes the more focused, in-depth experience required for Level III competency. COCATS 4 was charged with updating previously published standards for training fellows in cardiovascular medicine and establishing consistent training criteria across all aspects of cardiology, including echocardiography.2 For the cardiovascular fellowship, the following three levels of training have been delineated for training in echocardiography. 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 is not sufficient to provide independent interpretation of results. Level II training refers to additional training in ≥1 area that enables some cardiologists to perform or interpret specific diagnostic tests and procedures or render more specialized care for patients with certain conditions. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on their career goals and use of elective rotations. Level II echocardiography training is required to provide independent interpretation of echocardiograms. Level III training, the focus of this document, typically requires additional experience beyond the basic cardiovascular fellowship to acquire specialized knowledge and skill in performing, interpreting, and training others to perform specific procedures or render advanced, specialized care for procedures at a high level of skill. Level III training in echocardiography is required of individuals who intend to perform and interpret complex studies in special populations, lead a research program, direct an academic echocardiography laboratory, and/or train others in advanced aspects of echocardiography. Many of the competencies defined in this document overlap with those acquired during Level II training. For individuals seeking advanced echocardiography training, the intent is to gain these competencies at a deeper level during Level III training. Although Level III training in echocardiography may be achieved within a standard 3-year fellowship, for many individuals—especially those seeking expertise in multimodality imaging—an additional period of postgraduate training will be required. Fellows pursuing Level III training during the 3-year fellowship must devote all available elective time to echocardiography, usually precluding acquisition of Level II competency in any other imaging modality. As indicated in the COCATS 4, Task Force 5 report, training in echocardiography for at least nine cumulative months is generally required to ensure sufficient exposure to the range, volume, and diversity of clinical experience necessary for Level III competency. Ultimately, determination of whether a fellow has achieved Level III knowledge and skill should be based on the assessment of competencies defined in this training statement. For those who elect advanced training in echocardiography beyond the 3-year fellowship, the additional time may be dedicated solely to advanced echocardiography or part of a multimodality imaging training program. Although most trainees will achieve Level III training during a cardiology or advanced imaging fellowship program, the committee recognizes that selected individuals may acquire Level III competency after fellowship. Such an approach must adhere to the same rigorous standards (e.g., requirements for resources, clinical volume, faculty, evaluation) defined in this document. Level III training in echocardiography must always take place in laboratories with Level III trained faculty and with the necessary infrastructure to provide the advanced training experience. The recommended number of procedures performed and interpreted by trainees under faculty supervision has been developed on the basis of the experience and opinions of the members of the writing group and previously published competency statements, COCATS documents, and policies of the ACGME and NBE. In addition, the writing committee surveyed both cardiovascular and imaging training program directors for additional insight into procedural volumes. Of 234 directors of ABIM–recognized cardiovascular training programs surveyed, 67 responded; of 25 directors of imaging training programs surveyed, 11 responded. The procedural volumes and number of technical experiences suggested in this document were considered the minimum necessary to expose trainees to a sufficient range and complexity of clinical material and allow supervising faculty to evaluate the competency of each trainee. These procedural numbers (see Section 4.2.) are intended as general guidance and are based on the needs and progress of typical trainees in typical programs. Those considering these thresholds should bear in mind that procedural volumes are proxies for acquiring the technical proficiency and analytic skills essential for clinical mastery of echocardiography, which is the fundamental objective of advanced training. Engaged faculty committed to teaching are critical to the success of an advanced echocardiographic training program. The echocardiographic laboratory in which the training of cardiovascular fellows occurs must be under the direct supervision of a full-time qualified, Level III trained laboratory director. The Level III fellowship training will be under the supervision of a Level III NBE-certified echocardiography program director who may or may not be the laboratory director. The participating faculty should include specialists with broad and varied knowledge of all imaging modalities and echocardiographic techniques, including newly developed echocardiographic technologies. It is recommended that the majority of echocardiography faculty be Level III trained in echocardiography and board certified by the NBE. It is also recommended that anesthesiologists involved in training cardiology fellows in perioperative and interventional procedures have the equivalent of Level III training and certification by the NBE. Exposure to and close working relationships with these faculty will allow for a diverse and comprehensive training experience. In addition to developing, implementing, supervising, mentoring, and evaluating the fellows' clinical and research education, faculty should be involved in research and/or education. To provide advanced training in echocardiography, the laboratory environment must be located in an institution with an accredited general cardiovascular training program and should offer a broad range of outpatient and inpatient clinical diagnoses, including acquired and congenital heart diseases. The trainee should have access to both ultrasound equipment and offline workstations for performance and interpretation of 2D and 3D TTE and transesophageal echocardiography (TEE), Doppler echocardiography, contrast echocardiography, stress echocardiography, and strain imaging. The laboratory should perform echocardiography for a sufficient diversity of disease and corresponding volume to provide adequate exposure for the trainee. The training site's resources should allow correlation with other diagnostic data and patient outcomes. Intraprocedural echocardiography, including intraoperative, interventional, and electrophysiology laboratory procedures, should be available to the trainee. Direct experience with other cardiovascular imaging modalities and Level III experts in these modalities provides an important opportunity to understand the strengths and limitations of echocardiography relative to other techniques. The laboratory should conform to continuing quality improvement guidelines (e.g., ASE Recommendations for Quality Echo Lab Operations).5 Accreditation of the laboratory through the Intersocietal Accreditation Commission for Echocardiography is required. The training environment should also provide the trainee with participation in quality improvement initiatives, structured reporting, process improvement, application of Appropriate Use Criteria (AUC), and laboratory operations. It is recognized that some institutions may not be able to offer experience in all recommended procedures or adult congenital heart disease. Rotations at other sites with a high volume of structural procedures and/or congenital heart disease would be appropriate to accomplish these aspects of training.6 The echocardiography program director is responsible for verifying the quality of the training. Intersocietal Accreditation Commission accreditation is preferred for those additional sites but not required. Level III trainees should have the opportunity to interact regularly with other members of the healthcare team to learning and patient with experienced cardiac who are committed to training fellows and in the of settings and acquisition of is critical to should also have exposure to cardiologists from other as well as in other to address and treat the in patients undergoing echocardiographic specialists with echocardiographers interact include disease specialists, and the of specialists in critical care echocardiography, Level III trainees should the of critical care echocardiography and understand the of hemodynamic and related on echocardiographic This training may be by trained in the use of critical care echocardiography. As part of this Level III trainees will to provide subspecialty ultrasound performed in the care and under time in patients. In addition, skills with physicians and the healthcare team should be as part of Level III training. may take place in a variety of including clinical presentations, research training, and patient or quality improvement A program is intended to provide the advanced trainee with an understanding of ultrasound echocardiographic and and clinical application of echocardiography advanced application of ultrasound enhancing strain imaging, 3D echocardiography, stress imaging, and It should relevant including anatomy, and and it should advanced medical knowledge and patient care relevant to the competencies in Section In in the use of echocardiography in structural heart and cardiac should be of this training may be into the program for general cardiovascular training. However, Level III teaching should be within a multimodality imaging to appropriate and use of all cardiac imaging that fellows who advanced training in echocardiography will be to direct an echocardiography laboratory and train others in advanced aspects of echocardiography, should include exposure to the of laboratory (e.g., and equipment relationships with continuous quality as well as the opportunity to gain experience in Echocardiography an in the and of a variety of acquired and congenital cardiac exposure to the of heart in diverse patient should be available to the trainee. Although a minimum number of clinical is suggested (see Section these criteria as proxies for clinical experience. In of the quality of the experience and of the number of echocardiographic studies in which the trainee is important the range of and the quality of supervision and The trainee must develop expertise in understanding clinical in to echocardiographic in a that is relevant to the For the acquisition of technical skills, such as or stress echocardiography, this document provides minimum procedure volumes beyond those required for Level II training. The criteria described are similar to those in other on this topic. the available for the trainee is additional and experience beyond the numbers may be required to ensure appropriate Although Level III training can be achieved during the standard 3-year cardiology fellowship, additional training may be necessary or to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific Level III training in echocardiography requires rigorous clinical experiences in diverse clinical settings the various echocardiographic This would include experience in TTE and both 2D and 3D expertise in stress and with echocardiographic tools such as echocardiography, which is used for strain and strain In addition to experience with the use of echocardiography across the broad of cardiovascular exposure to echocardiographic evaluation of congenital heart disease is The sites of Level III training should include outpatient and inpatient care interventional cardiac laboratories and In each trainees should in procedures with and in procedural ultimately to achieve clinical and the to as a for a of the training with appropriate from an Level III trainees are expected to acquire and interpret and offline analytic tools and to their to the through a comprehensive In addition, trainees should be of the associated with echocardiography and to and, where avoid The trainee must review imaging studies and associated clinical outcomes The trainee should develop