Echocardiography Rotation

The echocardiography rotation at University Hospitals Cleveland Medical Center in conjunction with Case Western Reserve University is designed to enable fellows to achieve the knowledge, skills and attitudes of competent cardiologists needed to properly apply the echocardiographic methods used in the care of patients with known or suspected cardiovascular conditions. These methods include:

• Real-time three-dimensional transesophageal echocardiography (TEE)
• Stress (exercise and dobutamine) echocardiography (SE)
• Transthoracic echocardiography (TTE)

Comprehensive Training in Echocardiography and Imaging

Learning in the echocardiography rotation occurs through hands-on, supervised clinical procedures, daily reading sessions and divisional and departmental conferences. In addition to the interpretation of images, attending physicians are expected to reinforce the findings of the study to an understanding of the following about cardiovascular diseases:

• Clinical presentation
• Etiology
• Natural history
• Pathogenesis

Fellows begin learning to perform real-time three-dimensional transesophageal echocardiography (TEE) from their first year of the fellowship under supervision and develop excellent technical skills quickly.

Fellowship training in echocardiography includes instruction in the physical principles and instrumentation of ultrasound and cardiovascular anatomy, physiology and pathophysiology both in regard to the cardiovascular system in general and in relation to the echocardiographic examination in particular.

Fellows rotating through echocardiography at all levels are responsible for leading the weekly echocardiography conference under the supervision of the echocardiography director. They are expected to discuss interesting and educational cases for review with the echocardiography director prior to the conference and prepare a short didactic review complementing case studies. The goal of the conference is to expose fellows to the myriad echocardiographic aspects of cardiovascular disease.

Training Follows American College of Cardiology (ACC) Guidelines

Appropriate utilization of the health system resources is particularly important in the echo laboratory; this is highlighted by the recent development of appropriateness criteria by the American College of Cardiology (ACC) and related imaging societies. In addition to understanding these guidelines and integrating with other imaging technologies, fellows are expected to do the following, when feasible:

• Evaluate medical complaints in patients in the laboratory
• Participate in decisions regarding additional testing, care and triage
• Review relevant studies in patients referred for stress echo and TEE

Finally, fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, cardiologists and other members of the health care team.

Echocardiography Laboratory Excellence

The Echocardiography Laboratory at UH Cleveland Medical Center is a full-service, IACL-accredited multi-vendor laboratory performing over 10,000 TTEs, over 600 TEEs and over 800 SEs. Newer techniques (e.g., myocardial strain imaging, 3D TEE and deformation imaging) are used routinely. Systemwide integration of studies and interpretation on Syngo facilitates second opinions, ensures timely study interpretation and assists with quality assurance. There are nine ongoing clinical studies in the laboratory.

The echocardiography laboratory is committed to providing exceptional clinical service 24/7. In this regard, the on-call schedule applies to sonographers (limited call schedule), fellows and echocardiography attendings. Fellow call is dictated by the night float and weekend call schedules. Studies performed while on-call should be stored for review the next working day with the echo attending. A preliminary report should be entered in Syngo on any patient receiving an echocardiogram after-hours.

Core Cardiology Training Symposium (COCATS)

It is recognized that ultrasound is an evolving technology with an expanding list of methods and clinical indications. The core cardiology training symposium (COCATS) has defined three levels of expertise: The cardiology program at UH will provide Level 2 training for all cardiology fellows; Level 3 training is available but optional. Level 2 training provides the candidate the necessary knowledge and experience to be capable of performing and interpreting an echocardiographic examination (M-mode, 2D, TEE, exercise and pharmacologic stress echo) independently under the supervision of a laboratory director. Passing a qualifying examination (National Board of Echocardiography, NBE) is now required for Level 2 status. Other requirements include a minimum of:

• 150 TTE performed/300 supervised interpretations
• 25 TEE intubations/50 supervised studies
• 100 supervised stress echocardiograms
• 20 contrast studies

The third level of expertise requires additional training and will enable a trainee to direct an echocardiography laboratory, as well as perform various special ultrasound procedures, such as 3-D echo, myocardial perfusion imaging and myocardial strain echocardiography.

Principle Teaching Methods

Direct supervision of patient care: An attending physician provides supervision to all members of the team via direct patient care; this involves performing and interpreting TEE and stress echos and interpretation of TTE studies. Hands-on scanning is performed under the instruction and supervision of senior sonographers.

Case-based learning: Selected TTE, TEE and stress echos are used for in-depth discussions examining the clinical context of the echocardiographic study. Clinical data, previous echocardiograms, angiograms, CMR and CT studies, as well as pathology, are analyzed when available. These teaching sessions are seamlessly integrated into reading sessions and are analogous to daily attending walk rounds.

Didactics: The curriculum in echocardiography is formally presented in the core curriculum and the echo conference; other venues include divisional and departmental conferences.

Clinical Echocardiography Imaging Training

Patient characteristics: The mix of patients referred for an echocardiographic study are typical for a tertiary hospital and offers a wide range of pathologies from a broad racial, ethnic and socioeconomic population.

Procedures: Fellows learn TEE and stress echocardiography under the direct supervision of attendings. Advanced techniques, such as 3-D echo and strain rate imaging are routinely employed.

Principle Educational Materials

Fellows have 24-hour access to the core library located in the hospital with computer access to the following resources on all floors:

• Echo image databases
• Literature searching
• Online journals
• Textbooks
• UpToDate

Fellows are expected to be proficient in obtaining requisite information on pathophysiology from standard textbooks and medical literature. Current therapeutics should be guided by the medical literature with particular weight given to clinical guidelines and consensus statements issued by the American College of Cardiology, the American Heart Association and the American Society of Echocardiography.

Objectives by Post-Graduate Year

While both first- and second-year fellows rotate through the laboratory, expectations and independence vary by the level of training. Fellowship is a continuous process of professional and academic growth, with each individual progressing at a somewhat different pace and along a unique path. First-year fellows should spend mornings scanning with the sonographers during their first month and should become familiar with the procedures for recording, storing and retrieving images.

Initially, trainees interpret the echocardiogram with an attending, and as fellows progress, studies are read independently and subsequently reviewed with attendings. Senior fellows, as they obtain sophistication, judgment and knowledge, should take a prominent/leadership role in guiding education and patient care. Every cardiology fellow should be exposed to and familiar with the clinical performance, interpretation, strengths and limitations of TTE, TEE and stress echocardiography and their multiple clinical applications. All fellows are expected to progress in the six Accreditation Council for Graduate Medical Education (ACGME) competencies.

For More Information

For more information on the Echocardiography/Imaging Rotation, please contact:

Brian Hoit, MD
Brian.Hoit@UHhospitals.org