european tee certification
TRANSCRIPT
European TEE Certification
Dr John KneeshawMB ChB FRCA FESC
Chairman TEE Certification EAE/EACTACambridge UK
Friday, 13 April 12
‘When expertly used, perioperative echocardiography can lead to improved outcome in patients requiring
cardiac surgery …’
ASE/SCA Task Force Guidelines for Training in Perioperative EchocardiographyJ Am Soc Echocardiogr 15:647, 2002
Is intraoperative TEE useful in cardiac anaesthesia?
Friday, 13 April 12
Anesthesiology 2010; 112:1–1
Practice Guidelines for Perioperative Transesophageal
Echocardiography
An Updated Report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography
Friday, 13 April 12
In adult patients without contraindications, TEE should be used in all open heart (eg valvular procedures) and thoracic aortic surgical procedures......and should be considered in coronary artery bypass graft surgeries to:
1. Confirm and refine the preoperative diagnosis.2. Detect new or unsuspected pathology.3. Adjust the anaesthetic and surgical plan accordingly.4. Assess the results of surgical intervention.
In small children, the use of TEE should be considered on a case-by-case basis
Conclusions of ASA/SCA
Friday, 13 April 12
...more
Agreement that TEE should be used for patients undergoing transcatheter intracardiac procedures when general anaesthesia is provided and intracardiac ultrasound is not used.
Strongly agree that TEE should be used for septal defect closure or atrial appendage obliteration. Agree that TEE should be used during catheter-based valve replacement and repair.
Equivocal regarding the use of TEE during dysrhythmia treatment.
Friday, 13 April 12
Noncardiac surgeryStudies with observational findings or case reports note the detection of the following abnormalities by TEE:1) venous air embolism and PFO in neurosurgery (Category B2 evidence)2) pericardial effusion and compression in liver transplantation (Category B3 evidence)3) intracardiac emboli and patent foramen ovale (Category B2 evidence), mitral regurgitation, left ventricular hypertrophy, and left ventricular outflow tract obstruction in orthopaedic surgery (Category B3 evidence)4) left ventricular segmental wall motion abnormalities (Category B2 evidence), aortic lesions and atrial tumors in vascular surgery (Category B3 evidence),5) atrial septal defect, myocardial ischemia, hypovolemia, pericardial tamponade, thromboembolic events (Category B2 evidence), pericardial effusion, tamponade, and intrapulmonary emboli in other major surgery (i.e., lung, renal, abdominal, and head/neck/chest wall surgeries) (Category B3 evidence).
Agreement that TEE should be used for noncardiac surgical patients when the patient has known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary, or neurologic compromise. The consultants and ASA members both strongly agree that TEE should be used during unexplained persistent hypotension.
Friday, 13 April 12
TEE should be used when persistent unexplained hypoxemia occurs. TEE should be used when life-threatening hypotension is anticipated.
TEE should be used during either lung transplantation or major abdominal or thoracic trauma. The consultants agree although the ASA members are equivocal regarding the use of TEE during open abdominal aortic procedures and liver transplantation.
Equivocal regarding the use of TEE during:1) endovascular aortic procedures2) neurosurgery in the sitting position3) percutaneous cardiovascular interventions
(e.g., femoral artery stenting).
Noncardiac surgery
Friday, 13 April 12
The indications in critical care are mainly diagnostic.Particularly useful in unexpected and unexplained hypotension and hypoxaemia.
Critical care
Friday, 13 April 12
Why do we need standards and certification in TEE?
Cardiology
• Echo is core skill, but experience may be variable
• Many other physicians may have interests in echo
• Hand-held devices have transformed the market
Anaesthesiology
• Echo is not core skill in anaesthesia, but may become one.
• Cardiac anaesthesia has no defined range of skills or knowledge
• Variable level of training, experience and expertise with echocardiography
Friday, 13 April 12
Why do we need standards and certification in perioperative TEE?• Perioperative echocardiography requires a range of
skills, and a new mind set, which are new to anaesthesia.
• Cardiac anaesthesiologists are expected to be proficient in perioperative TEE, yet few have benefited from a formal education.
• Proper training avoids errors. (NB Comprehensive TEE)• Demonstrate that we are competent to assist surgical
decision making.• Medico-legal and quality assurance role in establishing
surgical performance.• TEE itself needs to be quality assured (complex
operations, new echo technologies).
Friday, 13 April 12
What is the significance of this systolic jet?
a) It is not significant. It is a normal closure jet for a bileaflet valveb) It is a small narrow insignificant paravalvular jet.c) It is an important paravalvular leak and should be fixed.d) It is insignificant, because the Colour Nyquist limit is wrongly set.e) I don’t know, call a cardiologist.
Friday, 13 April 12
Does examination and certification work?
• USA experience
• Development and analysis of a new certifying examination in perioperative transesophageal echocardiography. Aronson S et al, Anesth Analg 2003;96(6):1844
• 1200 participants 1995- 2001; 70% pass rate• Success positively correlated with echo
experience (78 examinations in 3 months)
Friday, 13 April 12
Is this just for anaesthetists?No
• USA decided that perioperative echo was different and so adopted a separate Perioperative Accreditation
• EAE/EACTA felt that the Certification was about TEE rather than the application (following UK example). Hence a unified process.
Friday, 13 April 12
The most likely explanation of his abnormality is
a) An intrac cardiac parasitic worm.
b) A thrombus passing through a PFOc) Thrombus in the mitral valve.
d) Thrombus in the aortic valve.e) Aortic dissection.Friday, 13 April 12
How did TEE certification develop
2002/3 Several meetings of the EACTA Committee on TEE with the European Association of Echocardiography (EAE)
2004 Foundation of a Joint TEE Accreditation Committee between EACTA and EAE.
Aims • To promote educaton in TEE.• To set a European standard for competence
and excellence in TEE.
• To be supportive of national processes.
2005 First pilot exam in Montpelier, France.
Friday, 13 April 12
European TEE certification governance
Governed by EAE Accredition CommitteeResponsible to the European Society of Cardiology.Includes: Lab accreditation and Individual certification in TTE, TEE, Congenital echo.
TEE Certification Committee has joint representation from EACTA and EAE
Chair John Kneeshaw (Cambridge) and Frank Flaschkampf (Upsala)Members from EACTA and EAE representing several countries.
Friday, 13 April 12
Supervisors
• The role of the local supervisor is important.• Supervisor is responsible for assuring that training has occurred,
and guarantees that the practical work has been done by the candidate.
• Supervisor must sign to say the candidate is fit to carry out TEE.• Supervisors would normally be expected to have held TEE
accreditation for at least 12 months.• In some countries very few individuals hold accreditation, and
candidates may nominate supervisors, who would normally be nationally recognised in TEE.
• In cases of doubt, consult with the appropriate National Society, Working Group, EAE or EACTA.
• The final decision regarding the suitability of a supervisor rests with the Certification Committee.
Friday, 13 April 12
a) Severe mitral stenosis b) Le1 ventricular failure c) Normal cardiac output
d) a and be) a and c
This clip is consistent with
Friday, 13 April 12
The examination• The exam is held under formal exam conditions.• There are 2 parts:
• A section testing theoretical knowledge.• A section on clinical cases using digital clips and stills.
• Needs a simple calculator• The exam is in English, a ‘Glossary of Terms’ used will be
available on the EACTA and EAE websites and for each candidate in the exam. Languages include French, German, Greek, Italian, Spanish Turkish and others.
• The validity of the exam process is continuously assessed by examiners external to the certification process (University of London).
Friday, 13 April 12
Written examination – Theory Section• This consists of 100 multiple choice questions which must be
answered within 120 minutes.• The questions test the candidates knowledge of the principles and
practice of echocardiography. • Approximately the first 20 questions will relate to ultrasound
physics, and the remaining to general echocardiography or TEE. Questions only relevant to TTE only will not be asked.
• Each question will have 5 possible responses and candidates will be asked to select the Single Best Answer.
• The examination will be written in a straightforward way to test knowledge.
• Clinical cardiology, or anaesthesiology, unrelated to echocardiography are not tested.
Friday, 13 April 12
Written Examination Reporting Section
• This will consist of 50 questions in minutes.• Each question will have 5 possible responses and candidates
will be asked to select the Single Best Answer.• Questions will be based on imaging material reflecting the
range of clinical conditions seen in current TEE practice in Anaesthesiology and Cardiology
• Normal or near normal studies may be included.
Friday, 13 April 12
Single best answer example
Dr Kneeshaw a) Is a great echocardiographerb) Has blue eyesc) Is giving this lecture d) Was born in Englande) Is a nice man
Is giving this lecture
Friday, 13 April 12
The echo shown is taken from an adult patient.Which is the single best answer?
a) There is a bicuspid aortic valve with mild regurgitation.b) There is marked dilatation of the aortic root.c) The setting of Nyquist limit is appropriate for the examination.d) The Colour Doppler signal demonstrates a very severe jet of
central regurgitation.
e) There is evidence of left main stem occlusion.
Friday, 13 April 12
The written examination - passmark
• You must to pass both the theory section and the echo reporting section on the same occasion.
• The pass mark will be set by the examiners based on the difficulty of the exam and is around 62/100 for the theory section and 30/50 for the echo reporting section.
• You can retake the exams as many times as you wish.• Accreditation will only be awarded to a candidate who has
passed the written exam and completed the logbook assessment.
Friday, 13 April 12
Practical Assessment (Logbook)• The practical assessment must be completed within a 24
month period. • The following must be completed:
Reports of 125 clinical TEE cases performed and reported ( in the national language) by the candidate
Summary sheetA letter from a supervisor testifying that the studies
were performed and reported by the candidateA letter from a supervisor confirming training and
review of studies undertaken by the candidate.Images from 6 cases must be uploaded as an
electronic logbook
Friday, 13 April 12
Log books• How should the echo logbook reports be formatted?
Tick box formats do not work wellSystematic text is betterData to support findingAnonymisedRead: Reporting perioperative transoesophageal echo studies. Robert Feneck, J. Kneeshaw, K. Fox, D. Bettex, J. Erb, F. Flaschkampf, F. Guarracino, M. Ranucci, M. Seeberger, E. Sloth, H. Tschernich, P. Wouters, Jose Zamorano. Eur J Echo 2010; 11: 387-393
• You have 24 months to complete the 125 cases, but the logbook should be submitted within 12 months of passing the exam.
• How much will it cost? (€170 for members)• E-logbook
Friday, 13 April 12
Not a good format
Friday, 13 April 12
Better format
Friday, 13 April 12
The logbook case mix
For cardiac anaesthesiologists, not more than 60% of cases should be for isolated CABG surgery.
The EAE accreditation committee will ask two external examiners to scrutinise 6 studies performed by the candidate to confirm that they have been appropriately performed and reported.
It is also strongly recommended that the candidate’s supervisor observes the candidate doing TEE studies.
Friday, 13 April 12
This patient has had an aortic valve replacement and has low blood pressure.
Friday, 13 April 12
What shall we do?a) Give some inotrope.b) Give the protamine. c) Call someone who knows about echo.d) Call a cardiologist.e) Go back on bypass and do another opera;on.
Friday, 13 April 12
What do I need to do?
• Enrol via EAE or EACTA websites.www.escardio.org/communities/EAE/accreditation/TEE/Pages/welcome.aspx
• Price 170 Euros members of EACTA/EAE (200 Euros non-members).
• Find a supervisor.• Education and practice.• Exams are twice each year.
• EACTA Annual Scientific Meeting (May/June)• EAE Euroecho (December)
• This year 2012: EACTA, Amsterdam, Netherlands Euroecho Athens, Greece
Friday, 13 April 12
E-Logbook
Desktop2
Friday, 13 April 12
Exam Evolution from 2005
0
20
40
60
80
100
200
5 EA
CTA
2005
EAE
2006
EAC
TA20
06 E
AE20
07 E
ACTA
2007
EAE
2008
EAC
TA20
08 E
AE20
09 E
ACTA
2009
EAE
2010
EAC
TA20
10 E
AE20
11 E
ACTA
2011
EAE
16
22
15
17
18
89
4
8
3
7
7
8
3 64
39
81
43
69
4348
12
43
2030
19
3729
PassFail
Friday, 13 April 12
Long Term VisionComputer based testing (CBT)
One laptop station per candidate linked to a central computerEasy markingAny European locationMay be more expensiveMinimal examiner time
Friday, 13 April 12
This clip is from a lady of 70 years who had cardiac surgery 10 years ago.She has sudden onset of extreme breathlessness and needed intubation and ventilation in Intensive Care.What has happened?
a) She has acute severe mitral regurgitation because of endocarditis.b) The biologocal valve that was implanted 10yrs ago has failed.c) She has heart failure caused by coronary artery disease.d) She has severe tricuspid regurgitation.e) I don’t know, call a cardiologist.
Friday, 13 April 12
Conclusion
• European certification in TEE is for cardiologists and anaesthesiologists and is available now.
• EACTA and EAE are committed to this process, and determined to ensure that it is relevant and accessible to cardiac anaesthesiologists.
• Further information from www.eacta.org and www.escardio.org/EAE
Friday, 13 April 12
Thank You!
Friday, 13 April 12
Friday, 13 April 12