Educational Purpose
There are 1-3 months dedicated to echo training in the second year, depending on the path chosen by the fellow.
When fellows return to the echocardiography laboratory in their second year, the initial time is typically spent as a time of refresher because most fellows have been out of the lab for up to 6 months. This is also an opportunity for fellows to integrate the echocardiographic examination into what they have learned in other cardiovascular disciplines, such as cardiac catheterization, clinical cardiology and nuclear cardiology. The emphasis of training is shifted to from image acquisition to transthoracic echo interpretative skills and learning stress echo and performance of TEE.
Fellows will spend the majority of their time with the attending in the echocardiography laboratory. At this time the fellow will be expected to perform and interpret stress echocardiograms and gain a thorough knowledge of contrast echo techniques. Fellows will also perform transesophageal studies on a regular basis. At a minimum, a fellow must reach Level II training in transthoracic echo and complete at least 50 supervised transesophageal studies and 100 supervised stress echocardiographic studies to be certified to independently perform these procedures.
Fellows pursue further learning in transthoracic echocardiography (TTE), stress echo (SE) and learning to perform and interpret transesophageal echocardiography (TEE). The goal is to obtain level 2 training (6 months, total of 150 examinations performed and total of 300 interpreted), the minimum recommended training for a physician to perform and interpret echocardiograms independently. These requirements are specifically for transthoracic 2-dimensional and Doppler echocardiography.
Level 2 is defined as a minimum of an additional 3 months of training in echocardiography (6 months cumulative) and the addition of 150 transthoracic two-dimensional and Doppler examinations interpreted (300 cumulative exams interpreted). Additional training in special procedures, such as TEE and stress echocardiography, is detailed above. Although some experience in special procedures may be attained as a part of level 2 training, in most instances, full competence in these areas will require additional training beyond level 2.
Topics Covered: Sentinel Medical Knowledge and Patient Care Skills
- Use multiple formulae to calculate ejection fraction
- Stress echocardiography pitfalls and pearls
- Echo and Doppler features of hypertrophic cardiomyopathy
- TEE interpretation of infective endocarditis
- Constrictive vs. restrictive cardiomyopathy
- Exam planes of the coronary arteries in TTE and TEE
- Further echo interpretation of congenital disease including Tetralogy of Fallot and transposition of great arteries (TGA)
Clinical Encounter Experiences
- patients with hypertrophic cardiomyopathy and aortic stenosis
- patients with mitral stenosis and regurgitation (assess Wikins score)
- patients with effusive-constrictive and restrictive cardiomyopathy
- patients with complex congenital abnormalities including a Fallot’s Tetralogy, transposition, repaired congenital heart disease (Mustard, Senning, Waterston)
Teaching Methods
An advanced level of didactic teaching is provided during these months of fellowship training, including:
- lectures in valvular heart disease
- hypertrophic cardiomyopathy and calculation of LV outflow gradients
- differentiation between constrictive and restrictive cardiomyopathy
- advanced training in stress echocardiography such as viability testing
There is a daily teaching session, which includes both anatomical and Doppler topics. At the bedside fellows are taught how to optimize ultrasound images, perform shunt calculations, obtain contrast images, perform basic congenital heart echo studies and administer Dobutamine during stress echocardiography.
Bedside TEE training: the physician performing a TEE must possess a broad range of knowledge related to pharyngeal and esophageal anatomy, sedation, intubation and probe manipulation, complications and contraindications, and operating the ultrasound machine, as well as good communication skills and a understanding of the basic principles of ultrasound imaging and Doppler hemodynamic assessment (more info).
Teaching conferences: echocardiography conducts weekly, one hour organized teaching meetings that include the ultrasonographers, echocardiography fellows and echocardiography attendings. Fellows are expected to present relevant echocardiographic studies at this and other conferences such as the catheterization conference. In addition, there is a monthly joint radiology and cardiology imaging conference. Echo fellows are expected to assist in selecting appropriate cases and in presenting cases at this conference. This conference helps to highlight the strengths and limitations of various cardiac imaging modalities.
Procedure Types Performed
Fellows perform a complete transthoracic echocardiography exam at an advanced level including:
- Doppler
- tissue Doppler
- diastology
- contrast (microbubble) and congenital TTE exam
Fellows perform stress echos including:
- Dobutamine stress echo (DSE)
- transesophageal echo (TEE)
Service Types Performed
Services performed by on-call echocardiography (stat echos) are described in detail (see year 1, month 2).
TEEs on nights and weekends are performed and interpreted by the on-call fellow under direct physical supervision of the on-call echo attending.
Other services performed:
- stress echocardiogaphy
- transthoracic echo in special settings (cath lab during balloon mitral valvuloplasty (PBMV)
- transesophageal echo