Purpose:

The overall purpose of the echocardiography rotation is to provide trainees with a general overview of all aspects of cardiac echocardiography and to ensure fellows acquire the necessary expertise required to perform and interpret transthoracic, transesophageal, and stress echocardiography studies which are routinely encountered in the practice of cardiology.

Each cardiology fellow will rotate on the University of Iowa Hospitals & Clinics echocardiography service for at least three months during the course of their fellowship. On this rotation, the fellow will learn principles of echocardiography as pertains to the evaluation and management of patients with general cardiac disorders such as heart failure, coronary artery disease, valvular disorders, pericardial diseases, and cardiac masses.

Responsibility/Specific Duties:

1. The fellow is the point of contact for all echocardiography services at UI Hospitals & Clinics.
2. Fellows should generally arrive at the lab by 8:00 am (or immediately following morning conference) Monday through Friday and is expected to stay until all studies are read by the attending cardiologist. Weekend echo coverage is provided by the on-call fellows.
3. Fellows will perform at least 2 transthoracic echocardiographic studies with the sonographers each day. These studies are to be performed and recorded as if the fellow is the sonographer, and the performing fellow should be identified in the study information section. The echo fellow should pre-read all scans performed.
4. Fellows will pre-read as many echocardiograms performed in the lab during the course of the day as possible (at least 10 studies / day)
5. Fellows will formally read the echocardiograms with the attending cardiologist every day.
6. Fellows will review all TEE requests and assist in scheduling the procedure in a timely fashion. The fellow will notify the attending immediately if a TEE is deemed urgent.
7. Fellows are encouraged to oversee and attend all stress echo procedures in the echo lab during which time they will become acquainted with the performance and interpretation of transthoracic studies.
8. Fellows will attend to all emergencies encountered in the Echo Lab during routine TTEs, TEEs, or stress echocardiograms.
9. The echo fellow is expected to remain in the general vicinity of the Echo Lab throughout the day and is expected to notify the lab staff if there are any conflicting schedules including vacation.
10. Fellows should be available and participate in performing contrast echocardiography or amyl nitrite studies, as well as supervising, performing and interpreting exercise and dobutamine echo studies. The echo lab serves as a good venue to acquire the necessary skills in exercise testing as a part of the exercise stress echocardiography laboratory studies.
11. Fellows are responsible for screening all inpatient transesophageal echocardiograms for appropriate indications and contraindications and for preparing both inpatients and outpatients referred for this procedure. The specific responsibilities include: obtaining consent to perform the TEE, assessing the indications and safety of the procedure, reviewing any pertinent pre-procedure data (e.g., labs or TTE), and discussing the case with the echo attending for that day. The pre-requisite to performing TEE’s is to perform and document 25 esophageal intubations under supervision. All fellows must perform and record at least 30 transthoracic echos prior to being eligible to participate in transesophageal echos
12. The echo fellow will attend the weekly echo conference and may be asked to perform a mini review of a topic based on an interesting case seen during their rotation through the echo lab.
13. The fellow will keep a log of all the TTEs, TEEs, and stress echos performed and interpreted during the course of the rotation. This log will be reviewed by the program director during the biannual review.
14. The fellow is expected to interpret and sign all EKG’s in the echo box daily. These EKG’s are located in the EKG lab and are to be completed by 10:00 am.

Supervision:

The UI Hospitals & Clinics echo fellows will pre-read or simultaneously read studies with the staff physician. This will facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatment of various cardiac disorders. The attending will review and constructively critique the fellow’s interpretations of all TTE, TEE, and stress echo studies. The attending will review and constructively critique the fellow’s performance of TTE. The attending will directly supervise the fellow’s performance of all TEE procedures. The attending will provide didactic sessions on basic concepts in echocardiography and may assign readings or other learning activities as necessary.

Learning Objectives:

1. Obtain training in the principles and methods of echocardiography as related to patients with a variety of cardiovascular diseases. (B)
2. Become proficient in obtaining adequate two-dimensional echocardiographic images with complete spectral and color Doppler data as is routinely acquired. This includes learning proper transducer manipulation and ultrasound system adjustments. Mastering correct transducer manipulation is critical to obtaining optimal image quality and optimal Doppler flow velocity signals. Fellows are expected to acquire a working knowledge of ultrasound instrument settings, such as transducer frequency, harmonics, mechanical index, depth, gain, time-gain-compensation, dynamic range, filtering, velocity scale manipulations, and the display of received signals. (B)
3. Gain an understanding that becoming skilled in the performance of TTEs facilitates the physician's understanding of optimal echocardiographic data acquisition and technical quality and this knowledge adds to proper interpretation and diagnostic accuracy of studies. (B, C)
4. Acquire skill in the various techniques of echocardiography including 2D imaging, color-flow Doppler, and both pulse-wave and continuous-wave spectral Doppler. (B)
5. Learn the indications and limitations of transthoracic echocardiography. (B)
6. Become proficient with the use of echo contrast and its various indications and uses. (B)
7. Become proficient in performing and interpreting transesophageal echocardiograms and learn the indications, limitations, and risks of the procedure. (B)
8. Learn the elements of safe administration of conscious sedation. (A, B)
9. Become proficient in the interpretation of stress echocardiograms and learn the indications, limitations, and risks of the procedure. (B)
10. Acquire basic knowledge of ultrasound physics. (B)
11. Understand the proper use and maintenance of echo equipment. (B, F)
12. Gain exposure to a broad range of acute and chronic cardiovascular problems through direct patient imaging and through formal and informal didactic teaching sessions. (B)
13. Gain a better understanding of the anatomy and physiology associated with a broad variety of cardiac disorders. (B)
14. Learn to use acquired echo data to assess intracardiac pressures and hemodynamics. (B)
15. Learn to use acquired echo data to detect and quantify cardiac valvular stenosis and regurgitation as well as other abnormal flow states, such as intracardiac shunts. (B)
16. Learn to communicate echocardiographic findings at a level appropriate for patients, family members, and members of the health care team. (D, E, F)
17. Gain an appreciation for the role of the members of the echo lab staff, including the sonographers, nurses, and administrative staff. (D, E, F)
18. Learn to generate accurate, thorough yet efficient, and understandable echo reports which clearly answer the question being asked. (D, E, F)
19. Learn to coordinate with other cardiology services (e.g., EP for TEE cardioversions, the Cath Lab for PFO/ASD closures or pericardiocentesis, CHF/TXP service for donor echo studies, etc) and thereby gain an understanding of how the health care delivery system can be used to the maximal benefit for patients. (F)
20. Learn to coordinate Echo Lab procedures with other medical and surgical services and thereby gain an understanding of how the health care delivery system can be used to the maximal benefit of patients. (F)
21. Gain hands on scanning experience by interacting with sonographers that will lead to the ability to perform high quality scans with measure to provide good echo lab quality control. (D, E, F)
22. Complete the specific training requirements for the desired level of certification as outlined by COCATS 3 and the American Society of Echocardiography. (B)< >It is important to emphasize that the numbers of examinations refer to comprehensive two-dimensional and Doppler echocardiographic studies that are diagnostic, complete, and quantitatively accurate.The actual number of procedures required to accomplish clinical competence in echocardiographic procedures is somewhat arbitrary, because there is individual variation in cognitive, analytical, and manual-dexterity skills. The listed numbers are therefore the minimum requirements anticipated to properly train the average cardiology fellow, and individual fellows may be required to perform additional studies as determined by the echo lab staff physicianMinimum training standards for transthoracic echocardiography are as follows:Training LevelCumulative DurationCumulative Number of
    Cases PerformedCumulative Number of 
    Cases InterpretedI375150II6150300III12300750

    
    All fellows are required to fulfill criteria for Level Criteria for Level I training. In addition, fellows are encouraged to perform 50 supervised TEE studies and 100 exercise echo and dobutamine echo studies.

    Level Specific Goals and Objectives:

    Junior Fellows (first year fellows)

    Fellows will pre-read echocardiograms and enter their preliminary findings in Excelera. They will then review these studies with the staffing physician. Fellows may be requested to monitor the stress portion of the exercise stress echocardiography studies. Each study will then be reviewed by the fellow with the staff. Findings will then be communicated with the referring physician. Fellows will share responsibility for assisting with Saturday TEE studies on Stroke Unit patients. These procedures are performed in the CVICU at 10 AM on an as needed basis. Fellows will keep a log of patient studies reviewed and performed.

    Senior Fellows (second year fellows and above)

    In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

    Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

    Both men and women of all adult ages and various ethnic backgrounds undergo echo Lab procedures. Patients presenting to the Echo Lab have a variety of cardiac disorders, including coronary artery disease, valvular heart disease, congestive heart failure, and pericardial disease. Procedures performed include the acquisition and interpretation of transthoracic, transesophageal, and exercise and pharmacologic stress echocardiograms. Clinical encounters include brief pre-procedure evaluations on the inpatient wards and in the Echo Lab prior to performing TEEs, performing the requested procedure, and providing any immediate post-procedure follow-up.

    Teaching Methods:

    The attending will review the fellow’s performance and interpretation of echocardiographic studies and provide constructive feedback including discussion of accurate interpretation. There will be daily echo reading sessions that will focus on interpretive skills and will cover the range of echo topics in brief case-directed teaching sessions. The attending may assign readings or other learning activities. The attending will directly supervise the fellow in the performance of TEEs. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending. A weekly didactic and case-based echo conference will be conducted by one of the echocardiography attending with active participation and presentation by the echo fellow.

    Evaluation:

    1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
    2. The fellow’s progress will be reviewed verbally mid-rotation.
    3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
    4. The attending’s final evaluation will be based on the fulfillment of the rotation objectives as determined by:
       1. Personal observation during interaction with the fellow in echo reading sessions and in the performance of echo procedures.
       2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
       3. Progressive improvement in the ability to adequately acquire TTE data.
       4. Progressive improvement in the ability to safely and properly perform TEEs.
       5. Progressive improvement in the ability to correctly interpret TTEs, TEEs, and stress echocardiograms.
       6. Participation at Echo Conference.
       7. Feedback from other team members, other healthcare providers (sonographers, echo lab administrative personnel, and patients).

Resources:

• University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
• www.cardiosource.com
• Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
• Otto’s Textbook of Clinical Echocardiography (4th edition)
• Feigenbaum’s Echocardiography (7th edition)
• The Echo Manual by Oh et al (3rd edition)
• www.asecho.org