Anesth Analg 2003;97:313-322
© 2003 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Clinical Competence in Echocardiography
Daniel M. Thys, MD FACC, FAHA
Department of Anesthesiology, St. Luke’s-Roosevelt Hospital Center, New York, New York
Address correspondence to Daniel M. Thys, MD, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave., New York, NY 10025. Address e-mail to dthys{at}chpnet.org
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Introduction
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In 1998, the American College of Cardiology/American Heart Association/American College of Physicians–American Society of Internal Medicine (ACC/AHA/ACP–ASIM) formed a Task Force on Clinical Competence to develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. In 2002, this task force appointed a writing committee to revise the 1990 ACP/ACC/AHA Clinical Competence in Adult Echocardiography document (1). The writing committee consisted of recognized experts in echocardiography representing the ACC, AHA, ACP–ASIM, American Society of Echocardiography (ASE), Society of Pediatric Echocardiography (SOPE), and the Society of Cardiovascular Anesthesiologists (SCA). The writing committee developed a new ACC/AHA Clinical Competence Statement on Echocardiography. The statement has been approved for publication by the governing bodies of the ACC and the AHA (2,3), and endorsed by the ASE, SCA, and SOPE. With permission from the sponsoring organizations, the current article summarizes the ACC/AHA/ACP–ASIM recommendations.
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Purpose of This Clinical Competence Statement
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Several previous publications have focused on training requirements for clinical competence in echocardiography (1,4–6). These earlier recommendations were limited primarily to the practice of transthoracic echocardiography (TTE) in the adult patient. However, over the past 15 yr, echocardiography has evolved into a family of techniques (Table 1), each one with unique applications and its own set of cognitive skills and training requirements. Today, most of these newer technologies are used routinely in community hospitals all across the nation. In addition, the application of echocardiography in children and adults with congenital heart disease (CHD) has evolved into a highly specialized modality with its own set of cognitive skills and training requirements. The recently formed National Board of Echocardiography (NBE) has also introduced guidelines for certification of special competence in adult echocardiography, which includes passing an examination in addition to specific training requirements. Separate certifications are granted for transesophageal echocardiography (TEE) and stress echocardiography. The NBE is developing a similar certification process for perioperative echocardiography. The current clinical competence statement provides a new set of recommendations that recognize the different cognitive skills required for each of the new modalities and that address training, documentation, and maintenance of competence.
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Document Format
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This document addresses competence in the performance and interpretation of all the different modalities of echocardiography, including new applications of echocardiography in the operating room and the application of echocardiography in patients with complex CHD. The document also addresses the application of echocardiography using miniaturized hand-carried ultrasound instruments. For each of the applications, there is a brief general overview, a discussion of the cognitive skills required, and recommendations on training requirements, proof of competence, and maintenance of competence. Whenever possible, these recommendations are linked to previously published recommendations made by specialty societies. In some situations, however, the writing group provides a set of recommendations that represent the consensus of this body of experts.
This document makes an important distinction between training requirements and documentation of competence. Training requirements represent the minimal training experience necessary to achieve the skills for performance at a particular level. It is recognized that training is highly individualized and that some trainees may require larger volume and more hours of exposure to a particular technique. Proof of competence, however, consists of a set of requirements that provide some assurance that physicians have gained the expertise needed to perform according to recognized standards.
The sections on training requirements refer primarily to the training needed to achieve specific levels of expertise. Such training is expected to occur under the direct supervision of a qualified Level 3 or equivalent physician/teacher and for the most part, occurs during formal fellowship training in either cardiovascular medicine or cardiovascular anesthesiology. However, the document recognizes that physicians trained before the development of these techniques may have properly learned their use while in practice. Thus, whenever possible, the document addresses training requirements and proof of competence for this group of physicians. Maintenance of competence requires the performance of a certain minimal volume of procedures and participation in continuing medical education (CME). This document recommends that physicians practicing echocardiography obtain a minimum of 5 h per year of CME credits in echocardiography, as recommended recently by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories.1
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General Principles
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Regardless of the echocardiographic modality used, there is a body of knowledge required by any physician involved in performance and/or interpretation of echocardiograms that includes ultrasound physics and use of instrumentation, anatomy, physiology, and pathology of the heart and great vessels (Table 2).
Basic Knowledge of Ultrasound Physics.
Echocardiographic imaging and Doppler systems generate ultrasound signals. Appropriate use of these instruments and interpretation of the data generated require an understanding of the fundamental principles of ultrasound physics and how they relate to the images produced and the spectral and color Doppler information. This understanding is considered to be an important requirement for clinical competence in all modalities of echocardiography.
Technical Aspects of the Examination.
An essential component of the diagnostic accuracy of echocardiography is the skill and experience of the individual responsible for image and data acquisition. Technical skills related to echocardiographic data acquisition may be divided into two important skill sets: transducer manipulation and ultrasound system adjustments. Perhaps the most difficult and underestimated skill set to master is transducer manipulation, which is critical to obtaining optimal image quality in standard tomographic imaging planes, and optimal Doppler flow velocity signals. This is true regardless of the type of transducer used (i.e., transthoracic, transesophageal, or intravascular). The second set of technical skills includes appropriate knowledge of ultrasound instrument settings such as transducer frequency, use of harmonics, mechanical index, depth, gain, time-gain-compensation, dynamic range, filtering, velocity scale manipulations, and display of received signals.
Anatomy and Physiology.
Echocardiography is a powerful diagnostic tool that provides immediate access for the evaluation of cardiac and vascular structures and assessment of heart function. Intrinsic to a competent echocardiographic examination is a thorough understanding of the anatomy and physiology of the heart and great vessels. Two-dimensional imaging can accurately quantify cardiac chamber sizes, wall thickness, ventricular function, valvular anatomy, and great vessel size. Pulsed, continuous-wave, and color-flow Doppler echocardiography, especially when combined with two-dimensional imaging, can be used to quantify blood flow velocities and calculate blood flow; assess intracardiac pressures and hemodynamics; and detect and quantify stenosis, regurgitation, and other abnormal flow states. Documentation of normal and abnormal cardiac anatomy and physiology must be accomplished by the individual performing the examination.
Recognition of Simple and Complex Pathology.
The ability to recognize both simple and complex pathology of the heart and great vessels is required for competence in echocardiography. A fundamental knowledge of cardiac pathology is required during data acquisition to tailor the examination appropriately and maximize demonstration of the abnormalities present. This includes the ability to modify standard imaging planes and optimize the Doppler beam angle of incidence to achieve this goal. In addition, an extensive knowledge of pathology and pathophysiology is required to interpret recorded echocardiographic data.
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TTE in Adult Patients
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Two-dimensional and Doppler TTE is one of the most important and frequently performed diagnostic procedures for patients with cardiovascular disease. It provides highly accurate diagnostic information regarding the anatomy and physiology of the cardiac chambers, valves, major vessels, and pericardium in a noninvasive and instantaneous manner. This information can immediately affect the further diagnostic work-up for the patient, dictate therapeutic decisions, determine response to therapy, and predict patient outcome. Because two-dimensional/Doppler TTE has such a major role in the care of patients with suspected or known cardiovascular diseases, the widely accepted indications for the procedure span the breadth of cardiovascular medicine. The minimal knowledge required for performance and interpretation of TTE is listed in Table 3. Although the number of procedures required to accomplish clinical competence in two-dimensional Doppler echocardiography is somewhat arbitrary because there is individual variation in cognitive, analytical, and manual-dexterity skills, recommended training requirements are listed in Table 4. CME in echocardiography is essential to keep pace with technical advances, refinements in established techniques, and applications of new methods. A program for continuous quality improvement in echocardiography should be used as outlined in the ASE Continuous Quality Improvement document (7).
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TEE
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TEE provides an excellent window for examining the heart and great vessels. In many large echocardiography laboratories, TEE studies represent between 5% and 10% of the total volume of echocardiographic examinations. TEE is a minimally invasive procedure with small but definite risks (8). Therefore, it should be reserved for clinical circumstances in which the potential findings have significant implications for patient management and cannot be obtained by transthoracic evaluation. The specific cognitive and technical skills needed to perform TEE in a competent manner are listed in Table 5, whereas the training requirements are listed in Table 6 (9).
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Perioperative Echocardiography
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Overview and Indications for the Procedure.
Perioperative echocardiography refers to the application of echocardiographic examination techniques in patients undergoing surgical procedures (intraoperative echocardiography) and during the early postoperative period. Early echocardiographic examinations used epicardial echocardiographic probes that had limited clinical applicability. Today, the examination is performed predominantly through the transesophageal approach, although epicardial and epivascular techniques continue to have a role during surgery, particularly in the echocardiographic assessment of the thoracic aorta.
Perioperative echocardiography uses most of the echocardiographic modalities used in the nonoperative setting. They include M-mode and two-dimensional imaging techniques as well as pulsed, continuous-wave, and color-flow Doppler. Most modern transesophageal probes have multiplane capabilities. The ASE and the SCA have published guidelines for the performance of a comprehensive perioperative multiplane transesophageal examination (10). The indications for perioperative echocardiography have been summarized by a task force of the American Society of Anesthesiologists/SCA and published as practice guidelines in 1996 (11). They can be divided into two broad categories: 1) indications that lie within the customary practice of anesthesiology, such as the perioperative diagnosis of myocardial ischemia and infarction, the perioperative assessment of hemodynamics and ventricular function, and the perioperative diagnosis and management of cardiovascular collapse; and 2) indications that guide surgical decisions in the operating room. In this regard, cardiovascular lesions are diagnosed, and the information is used to influence the patient’s surgical management. The results of surgical interventions may be assessed by echocardiography, and the findings may guide additional surgical therapy, if necessary. A physician should perform the perioperative echocardiographic examination. Although a sonographer may assist the physician, the physician must always be present to interpret the echocardiographic data and assist the surgeon in planning the surgical procedure.
Minimal Knowledge Required for Performance and Interpretation.
Competence in performing and interpreting perioperative echocardiography in adult patients requires basic knowledge of ultrasound physics, instrumentation, and cardiac anatomy, physiology, and pathology outlined in the section on General Principles. Although several guidelines describe the knowledge necessary to perform echocardiography, few have focused on the specific knowledge and skills necessary for the practice of perioperative echocardiography. Specific guidelines on training in perioperative TEE have been recently published by an ASE/SCA Task Force (12). These recommendations, which were developed mainly for anesthesiologists, recognized that perioperative echocardiography was practiced at different levels. Some anesthesiologists predominantly use echocardiography for monitoring purposes in the detection of myocardial ischemia or the evaluation of intracardiac hemodynamics and ventricular function (basic level), whereas others use the full diagnostic potential of echocardiography in the perioperative period (advanced level). The knowledge and skills necessary to practice perioperative echocardiography at the basic and advanced levels were defined in the ASE/SCA training guidelines (12).
Training Requirements.
The ACC/AHA Clinical Competence Statement endorses the recent American Society of Anesthesiologists/SCA and ASE/SCA task force recommendations of two levels of training for perioperative echocardiography, basic and advanced (11,12). Both basic and advanced TEE training refer to specialized TEE training that extends beyond the minimal exposure to echocardiography that occurs during normal anesthesia residency training. Anesthesiologists with basic training are considered able to use TEE for indications that lie within the customary practice of anesthesiology. Anesthesiologists with advanced training are, in addition, able to use the full diagnostic potential of perioperative TEE.
The essential components of training include independent work, supervised activities, and assessment programs. Through a structured independent reading and study program, trainees must acquire an understanding of the principles of ultrasound and indications for perioperative echocardiography. This independent work should be supplemented by regularly scheduled didactics such as lectures and seminars designed to reinforce the most important aspects of perioperative echocardiography. Under appropriate supervision, trainees undergoing basic training learn to place the TEE probe, operate the ultrasound machine, and perform a TEE examination. Trainees should be encouraged to master the comprehensive examination defined by the ASE and SCA (10). The training recommendations for basic and advanced perioperative echocardiography are summarized in Table 7.
Proof of Competence.
Documentation of competence can be achieved by means of letters or certificates from the director of the perioperative echocardiography training program (Table 8). This documentation should state the dates of training and that trainees have successfully achieved or surpassed each of the training elements. Physicians already in practice can achieve appropriate training in perioperative echocardiography without enrolling in a formal training program. However, the same prerequisite medical knowledge, medical training, and goals for cognitive and technical skills apply to them as they apply to physicians in formal training programs. They should work with other physicians who have advanced TEE training or equivalent experience to achieve the same training goals and case numbers as the training levels previously delineated. It is the consensus of this writing group that physicians seeking basic training via this pathway should have at least 20 h of CME devoted to echocardiography. Physicians seeking advanced training via this pathway should have at least 50 h of CME devoted to echocardiography. The CME in echocardiography should be obtained during the time that trainees are acquiring the requisite clinical experience in TEE. Trainees should document their experience in detail and be able to demonstrate training equivalent in depth, diversity, and case numbers to the training levels previously delineated. Physicians who provide the training should document the successful completion of the training elements and the dates of training. The writing committee believes that, ideally, physicians should take the perioperative TEE board examination offered by the NBE and achieve NBE certification in perioperative echocardiography, when it becomes available.
Maintenance of Competence.
Clinical competence in perioperative echocardiography requires continued maintenance of skills in perioperative TEE including two-dimensional and Doppler examination (Table 8). Upon completion of the above training requirements, a minimum of performance and interpretation of 50 examinations per year is required to remain proficient in performing perioperative echocardiography. A program for continuous quality improvement in echocardiography should be used as outlined in the ASE Continuous Quality Improvement document (7). CME in perioperative TEE is essential to keep pace with technical advances, refinements in established techniques, and applications of new methods. Minimal CME requirements are outlined in the section Document Format.
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Stress Echocardiography
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Exercise electrocardiography is the standard noninvasive technique for the diagnosis of coronary artery disease. However, several situations (such as baseline electrocardiography abnormalities and inability to exercise) reduce the sensitivity or specificity of exercise testing, or preclude its use entirely. In these situations, stress echocardiography is an important alternative. There are two main modalities for performing stress echocardiography: 1) exercise stress echocardiography performed either during upright or supine bicycle exercise or immediately after treadmill exercise, and 2) pharmacologic stress echocardiography, most often performed using an IV infusion of dobutamine at a dose ranging from 5 µg · kg-1 · min-1 to a maximum of 40–50 µg · kg-1 · min-1. Atropine is added at peak infusion dose if needed to achieve at least 85% of target heart rate. Adenosine and dipyridamole can also be used as pharmacologic stressors. Atrial pacing using an esophageal lead or an implanted pacemaker is a third modality for performing stress echocardiography. Although it is not often used, this modality can provide an effective and safe method for inducing ischemia. An ACC/AHA Clinical Competence Statement on Stress Testing document by Rodgers et al. (13) addressed the cognitive skills, training requirements for establishing competence, and requirements for maintaining competence in stress echocardiography. They are adopted in the current document.
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Echocardiography for CHD Patients
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Echocardiography is an important resource used in the evaluation of infants, children, and adults with suspected or documented CHD. It has been widely applied for the last several decades and has become a mainstay in daily clinical use. As applied to infants, children, and adults with CHD, echocardiography comprises all of the previously described modalities. When combined, they provide a comprehensive anatomic diagnosis along with the assessment of associated flow disturbances. Such information is obtained noninvasively, without patient risk or discomfort. The high accuracy of the information is often sufficient to preclude the need for further invasive diagnostic studies such as cardiac catheterization. Numerous echocardiographic methods have been developed with high sensitivity and specificity for individualized diagnosis and assessment of disease severity. In addition to the method’s high accuracy, it has prime utility in serial evaluation of patients for surveillance of the severity and progression of the disease, and the response to therapy.
In most cases, a properly trained adult cardiologist with Level 2 or 3 competence in echocardiography should be capable of recognizing simple congenital heart defects (Table 9) and treating affected patients appropriately (14). However, the same does not apply to complex lesions. Few adult cardiology training programs have a sufficient caseload and case mix of complex lesions to ensure an adequate level of training. Although adult cardiologist echocardiographers may often recognize the presence of a complex CHD, the comprehensive evaluation and management of these lesions require special skills not usually acquired during a conventional adult cardiology fellowship. With the growing number of adults with complex CHD, there is an acknowledged need for cardiologists trained specifically in the care of these patients (15). Practitioners in adult CHD require special expertise in echocardiography similar to that possessed by pediatric echocardiographers. Training in complex adult congenital disease requires a minimum of 150 complete TTE and 25 TEE (10 intraoperative) studies performed and interpreted in patients with CHD, as well as participation in the interpretation of at least 300 TTE and 50 TEE studies (20 intraoperative) (16). Case mix is an important aspect of the training experience, and when adequate diversity is not available among adult patients, training should include echocardiographic examinations in children.
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Fetal Echocardiography
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Fetal echocardiography is the ultrasonic evaluation of the developing human cardiovascular system before birth. Noninvasive in nature, and highly accurate when used by skilled operators, it is presently the standard method used for the detection of fetal cardiovascular disease. A complete imaging evaluation of the fetal cardiovascular system can be obtained using a maternal transabdominal approach at 18–22 wk gestation; however, some images can be obtained as early as 14–16 wk. Transvaginal fetal echocardiography can be performed as early as 12 wk gestation. The increasing national trends toward routine performance of second trimester obstetrical ultrasound and toward overall improvements in the field of obstetrical diagnostics have led to a greater number of referrals to specialists knowledgeable in the field of fetal cardiovascular abnormalities and skilled in the performance of fetal echocardiography. Recent data demonstrate an improved postnatal outcome for CHD when a prenatal diagnosis via fetal echocardiography is made (17,18). Guidelines for physician training in fetal echocardiography were offered by SOPE Committee on Physician Training in 1990 (19). The current document endorses these recommendations.
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Emerging New Technologies
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Over the past few years, several new technologies or applications for echocardiography have emerged that continue to improve our ability to care for cardiac patients. Because they are new, there has not been sufficient experience with all of them for specialty societies to provide written recommendations regarding training requirements, documentation, and maintenance of competence. However, it is the consensus of this writing group that, because these new technologies are in current use, this document should provide, inasmuch as possible, a set of recommendations for training requirements and establishment of competence.
Hand-Carried Ultrasound (HCU) Devices.
The era of an "ultrasound-assisted" physical examination has arrived, brought about by improvements on an old concept of an "HCU scanner." An HCU device is defined as a small ultrasound machine (typically <6 pounds), with limited diagnostic capabilities designed for evaluating gross structural or functional abnormalities of the cardiovascular system, which does not fulfill the criteria for a current state-of-the-art limited or comprehensive echocardiographic examination (Table 10). The ASE has defined the principal use of HCU as a method of extending the accuracy of bedside physical examination (20). The instrument is designed primarily for a "focused" user-specific ultrasound examination. The intent is to appropriately reduce under- and over-utilization of more expensive technology. This definition implies that a state-of-the-art instrument is not always necessary to answer specific pertinent user questions. However, the words, "targeted" and "focused" are often equated with incomplete, inadequate, or inaccurate information, which may lead to inappropriate over- or under-utilization of this and other diagnostic methods or technology. It is the consensus opinion of this writing committee that "extension of the physical examination" should not be interpreted as a license for untrained individuals to use poor imaging techniques that will result in inaccurate diagnosis. The user of an HCU determines which image or information is important to the specific clinical question asked and must take personal responsibility for the quality and use of the obtained information. Consequently, the user should be held accountable for appropriate training, application, documentation, and interpretation of HCU data. Competence in performing and/or interpreting echocardiography using an HCU requires all of the basic knowledge of ultrasound physics, instrumentation, cardiac anatomy, physiology, and pathology described in the sections on General Principles and Adult Transthoracic Examination. Training and credentialing recommendations for physicians performing and interpreting adult TTE have been discussed in the section TTE in Adult Patients. The current document endorses the ASE recommendations that individuals using an HCU specifically for cardiovascular education or self-instruction should have at least a basic Level 1 of training, as outlined in Table 4. However, Level 1 training may not be adequate for the independent performance and interpretation of a clinical HCU examination. In this setting, the writing committee recommends Level 2 training as defined in Table 4. Individuals with less training must consult directly with an echocardiographer with Level 2 or 3 training. This will safeguard the patients’ interests and ensure accurate diagnoses, optimal management, and appropriate use of more expensive comprehensive examinations when necessary.
Contrast Echocardiography.
IV contrast agents are available for enhancing endocardial border delineation and improving the Doppler signal. The use of contrast with harmonic imaging provides opacification of the left ventricular cavity and improved endocardial border detection. The technique is especially useful in obese patients and those with lung disease. Stress echocardiography examinations can be challenging, and a short acquisition time is essential in delineating regional wall motion abnormalities induced by peak exercise. The use of contrast can improve the ability to obtain diagnostic information and/or increase diagnostic accuracy. The ASE Task Force on Contrast Echocardiography states that "IV contrast agents demonstrate substantial value in the difficult-to-image patient with comorbid conditions that limit an ultrasound evaluation of the heart" (21). Future applications may include the evaluation of myocardial perfusion at rest or during exercise or pharmacologic stress. Competence in the performance and interpretation of contrast echocardiography requires all of the basic knowledge of ultrasound physics, instrumentation, cardiac anatomy, physiology, and pathology described in the preceding sections. Unique to contrast echocardiography is the need to understand microbubble characteristics and their interactions with cardiac ultrasound, along with the indications and contraindications for various contrast agents. The basic prerequisites for independent competence in echocardiography (Level 2 training) must be met before or during the training experience with contrast. The operator performing contrast echocardiography in conjunction with other special cardiovascular ultrasound examinations, such as stress, perioperative, and TEE, must be in the process of completing or must have completed, the additional subspecialty training credentials recommended in this document.
Intracoronary and Intracardiac Ultrasound.
Intracoronary ultrasound is performed with a miniaturized flexible ultrasound catheter that provides detailed information of the vessel wall (22). The high-frequency transducers (e.g., 20–40 MHz) enable the acquisition of high-resolution images with limited depth of penetration. Today, this technology is not considered as an alternative to angiography but, rather, a complementary diagnostic technique. The clinical advantages associated with the use of intracoronary ultrasound have not yet been fully established in randomized trials. However, there is increasing evidence from large prospective studies that ultrasound guidance improves the results of catheter-based intracoronary interventions in terms of immediate lumen enlargement, reduced procedure-related complications, and long-term prevention of restenosis (23–25). Although intracoronary ultrasound has become a routinely applied diagnostic technique in interventional cardiology, few attempts have been made to standardize the examination procedure, the definitions, and the format of reporting qualitative and quantitative data. Indications for intracoronary ultrasound in association with coronary interventions include: 1) lesion assessment and selection of treatment; 2) detection and characterization of vascular/plaque calcium; 3) delineation of plaque eccentricity; 4) identification of type of vessel remodeling; and 5) intracoronary guidance during balloon angioplasty, directional atherectomy, and stent placement.
Intracardiac ultrasound catheters are of larger caliber and are suitable for entering larger vessels and fluid-filled cavities (26). This technology has been used to define cardiovascular anatomy, to guide procedures, and to assess the results of interventions. There are currently two catheter-tipped ultrasound transducer technologies: 1) radially arranged piezoelectric elements or rotating element transducers, which generate a two-dimensional radial image; and 2) linear or phased array transducers, which generate a longitudinal two-dimensional image. The intracardiac transducers are of lower frequency (5–10 MHz) to enable a greater depth of image penetration into blood or fluid-containing cavities and contiguous structures. The phased-array technology also incorporates a full complement of imaging, Doppler, and articulation features.
The use of intracardiac ultrasound has not been fully tested in randomized trials. However, it is reported that this technology can be used to: 1) guide and access the result of an interventional procedure and better visualize cardiovascular anatomy and physiology; 2) reduce radiation exposure; 3) substitute for TEE during interventional procedures; 4) aid in positioning interventional devices; 5) provide echo and Doppler anatomic and hemodynamic information; and 6) direct an atrial septostomy.
There are no currently published standards defining the minimal requirements for performance and inter-pretation of intracoronary or intracardiac ultrasound. However, similar to other emerging new technologies, competence in performing and/or interpreting the ultrasound examination requires all of the basic knowledge of ultrasound physics, instrumentation, cardiovascular anatomy, physiology, and pathology described in the sections on General Principles and TTE. Physicians performing the examination must also have skills in inserting and manipulating the catheter to obtain the required views and knowledge of normal anatomy and pathology of the structures seen with the ultrasound catheter. Training and competence requirements have not been defined. However, competence will assuredly require a minimal training comparable to Level 2 and a repetitive exposure to the technique consistent with the recommendations for other emerging technologies.
Echo-Directed Pericardiocentesis.
Cardiac tamponade is a serious, potentially life-threatening, condition that can be clinically challenging from both diagnostic and therapeutic perspectives. Presenting symptoms can be diverse and nonspecific (i.e., tachycardia, hypotension, increased jugular venous pressure, pulsus paradoxus) and may therefore be misinterpreted. Two-dimensional and Doppler echocardiography can readily confirm the presence of an effusion and provide accurate assessment of its hemodynamic significance.
Historically, the percutaneous pericardiocentesis procedure was essentially "blind," and serious complications were common. The introduction of echo-guided pericardiocentesis has substantially decreased both the major (1.2%) and minor complications (3.5%) of this procedure (27). Echo-guided pericardiocentesis is much less expensive and traumatic than a surgical pericardiocentesis. In addition, the echo-guided approach has resulted in the common use of a pericardial catheter for intermittent drainage, which has further reduced recurrence rates and the need for surgical management of the effusion. Echo-guided pericardiocentesis is considered to be the primary therapy for patients with clinically significant effusions, and it is often the definitive therapy. Success in the relief of tamponade is reported to be 97%; single needle passage provides access to the effusion in 89% of patients.
Competence in performing an echo-directed pericardiocentesis requires a basic knowledge of ultrasound physics, instrumentation, cardiac anatomy, physiology, and pathology as described in the sections on General Principles and TTE. In addition, physicians performing the procedure must have procedural skills in localizing the optimal entry site (i.e., where the fluid is closest to the skin surface), introducing the needle into the pericardial space, passing the guiding wire, and introducing a draining catheter when required. Physicians performing an echo-guided pericardiocentesis must meet established training and credentialing recommendations for performing a state-of-the-art limited or complete echocardiographic examination. Although training requirements have not been formally published, the writing committee recommends that trainees have at least a Level 2 echocardiography training and be personally tutored by an experienced Level 2 or 3 echocardiographer in the performance of at least 5–10 echo-guided pericardiocenteses.
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Footnotes
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1 ICAEL Newsletter 2001;4:5. 
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Accepted for publication March 20, 2003.
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Introduction
Purpose of This Clinical...