Noninvasive Cardiovascular Imagine Laboratory

Educational goals and learning objectives

The purpose of this rotation is to provide the fellow training in interpreting and performing 2D Echo, TEE, ETT and stress echos with exercise and with Dobutamine.

By the end of the fellowship, each trainee should be proficient with performance and interpretation of transthoracic echocardiography, including M-mode, 2-D, pulsed and continuous wave Doppler, and color flow imaging.

Our training goals are based on the Guidelines for Training in Adult Cardiovascular Medicine of the Core Cardiology Training Symposium (COCATS). During level 1 training, the fellow spends 3 months in the echo lab, performs 75 studies and interprets 150 supervised studies. To have sufficient training for independent echocardiographic interpretation, however, the fellow should perform and interpret at least another 150 supervised studies (level 2).

All fellows who wish to sit for the National Echo Board exam after fellowship must spend a total of 6 months in the noninvasive laboratory during their fellowship. Echo research and time spent during echo reading sessions will count toward this time.

During the Echo Lab rotation, the fellow also will be exposed to stress echocardiography and transesophageal echocardiography. To achieve competence in stress echo interpretation, trainees should have level 2 training (6 months) plus supervised interpretation of at least 50 stress echo studies. Similarly, competency in TEE requires level 2 training plus 75 supervised TEE procedures (which can include intra-operative studies).

Although all fellows should become familiar with stress and transesophageal echocardiography, not all trainees will ultimately specialize in these areas. TEE procedures may be performed preferentially by senior fellows interested in echocardiography (under attending supervision), although junior fellows may manipulate the TEE probe after diagnostic information is obtained. For each case, the attending will decide on the degree of fellow participation, based on patient stability and the urgency of the test. TEE must not be performed without faculty supervision. All fellows wishing to perform TEE should consider contacting the GI Suite for hands-on instruction in passing endoscopes.

For after-hours or weekend TEE or stat echo interpretations, an echo call schedule is available through the UCSD operator. If there are questions (or if an attending is unavailable), page Dr. Raisinghani, (619) 290-4307.

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Clinical encounter/procedures/services

  • Electrocardiography (ECG)
  • Exercise stress testing (Treadmill - ETT)
  • Holter and event monitoring
  • Echocardiography
    • Transthoracic: 2D, 3D & 4D
    • Transesophageal (TEE): 2D & live 3D
    • Contrast Echo
    • Resynchronization Echocardiography
  • Stress Echo
    • Exercise echocardiography
    • Pharmacologic stress echocardiography (Dobutamine stress echo)

Teaching methods

Hands-on teaching will be from the cardiac sonographers.

There are ample opportunities for the fellow to have hands-on experience performing echos in the Lab. These hands-on teaching will be directly supervised by a sonographer. The duration of each case may vary depending on the patient’s condition.

Due to the complexity of the procedure and the variety of equipment used in the Lab, the fellow is encouraged to practice with the transducer frequently. This will improve the hand-eye coordination and also improve his/her ability to perform a complete echocardiogram.

There are daily one-on-one echo interpretation sessions with the attending staff, which include interpretation of transthoracic echocardiograms and stress echo studies performed that day.

Disease mix/patient characteristics

The patients referred for studies to the noninvasive lab include both in- and out-patients. Critically ill inpatients may require emergent procedures. Routine inpatients and scheduled outpatients are mostly stable. Both genders are represented approximately equally, and the age of patients varies widely. A large proportion of patients undergoing echocardiography have coronary artery disease, heart failure, and/or valvular heart disease.

Type of clinical encounters/procedures/services

The great majority of patients encountered by the fellow in this rotation will be referred to the Noninvasive Lab for noninvasive imaging, including transthoracic echocardiography, transesophageal echo, exercise ECG testing, exercise echocardiography, and Dobutamine stress echocardiography. The fellow should be available to supervise all stress testing, and should evaluate all requests for TEE procedures. The fellow will obtain consent for TEEs, complete the H&P if needed, perform the procedures along with the attending physician and document the results.

Level of fellow supervision by faculty

Results of all echocardiographic and stress tests will be reviewed by the attending before a final report is prepared and approved. Fellows may supervise exercise and Dobutamine stress tests on their own, but all transesophageal echocardiograms must be performed under direct attending supervision. Fellows may perform transthoracic echocardiograms on their own or with sonographer supervision, but official reports can be generated only after an attending physician reviews and interprets the study. See below for expectations of fellow responsibility by level of training.

Reading list and educational resources

A partial list of currently available echo textbooks and review includes:

  1. Otto C. Textbook of Clinical Echocardiography.
  2. Feigenbaum H. Echocardiography.
  3. Weyman A. Principles and Practice of Echocardiography, 2nd Edition.
  4. DeMaria AN, Blanchard DG. The Echocardiogram. In: Fuster V, Alexander RW, O’Rourke R (eds): Hurst’s the Heart.
  5. Hagen A, DeMaria AN. Clinical Applications of Two-Dimensional Echocardiography and Cardiac Doppler.
  6. Labovitz AJ, Williams GA. Doppler Echocardiography: the Quantitative Approach.
  7. Nanda N. Atlas of Transesophageal Echocardiography.
  8. Nishimura RA, Miller FA, Callahan MJ, et al. Doppler echocardiography: theory, instrumentation, technique, and application. Mayo Clin Proc 1985; 60:32-43.
  9. Perez JE. Doppler Echocardiography: A Case Studies Approach.
  10. Waggoner AD, Perez JE. Principles and Physics of Doppler. Cardiology Clinics 1990,8:173-89
  11. Hatle L, Angelsen B. Doppler Ultrasound in Cardiology: Physical Principles and Clinical Applications.

Pathological material and other educational resources

A computer database of classic echo findings and interesting cases is available on the Lab’s digital system. Please ask the staff for assistance in viewing these.

The pathophysiology seen in the Lab will vary each month. Fellows are encouraged to read in order to fill out their knowledge base.

Evaluation

Each fellow will be evaluated monthly, with input from the attending staff and technical personnel. ACGME core competencies are evaluated monthly by the attending faculty. These evaluations are discussed with the fellows and forwarded to the program director. First-year fellows are expected to have a mean evaluation score of 5 or greater on the standard 1-9 scale of the 6 ACGME core competencies. Second-year fellows are expected to have a mean score of 6 or above. Third-year fellows are expected to have a mean score of 7 or above. Expectations of fellow performance vary by year of training.

First-year fellows are expected to grasp basic cardiac anatomy and the basic physics of two-dimensional and Doppler echocardiography. They are expected to have personally performed 25 transthoracic echos (TTEs) and 10 transesophageal echos (TEEs), and to have interpreted 100 TTE studies.

Second-year fellows are expected to be well-versed in cardiac anatomy and transthoracic echocardiography, and aware of more advanced concepts of transesophageal echocardiography. They should have personally performed 40 TTE studies and 25 TEE studies, and interpreted 75 TTE studies.

Third-year fellows are expected to become fully competent in transthoracic and transesophageal echocardiography and to have performed >50 TTE studies and >40 TEE procedures. Fellows who specialize in echocardiography may perform additional TTE and TEE procedures during their final year of training.

Educational purposes and ACGME Core Competencies

Specific activities during this rotation that will enhance the fellows’ skills in the 6 core competencies:

  1. Patient Care: This rotation does not include a large amount of direct patient care. Fellows will learn how to maximize patient comfort during stress echocardiography and will gain experience in the technique of conscious sedation during transesophageal echocardiography.
  2. Medical Knowledge: Fellows will gain experience and knowledge in echocardiography and cardiac imaging during the performance of transthoracic and transesophageal echocardiography, during daily teaching rounds with attending faculty, during review of teaching files, and during self-directed learning and reading.
  3. Interpersonal and Communication Skills: Fellows will interact with cardiac sonographers, noninvasive staff personnel, and nurses. They will be expected to keep accurate, timely-signed medical records and procedure reports. Fellows will be expected to notify the attending and/or requesting physicians of any critical findings and document such notifications.
  4. Professionalism: Fellows will gain experience in the respectful treatment of all the above-mentioned groups, and will also maintain accurate procedure logs and hospital privileges.
  5. Practice-Based Learning: Fellows are expected to gain knowledge from self-directed literature and on-line review concerning interesting echo cases they encounter, and facilitate the education of internal medicine residents rotating on the Cardiology Consultation Service. Fellows may present cases during journal club and weekly catheterization conference, and discuss pertinent literature.
  6. Systems-Based Practice: There is not substantial activity in this Competency during the Echo Lab rotation.

Cardiac Non-Invasive Staff

  • Ajit Raisinghani, M.D., Medical Director (pager 290-4307)
  • G. Monet Strachan, RDCS Manager and Technical Director
  • Mahtab Abbasi, RDCS
  • Baker, Keefe, RVT
  • Shamonda Block-Brooker
  • Irina Bronshteyn, RDCS
  • Kela Dashi, RDCS
  • Joseph De Los Reyes, RDCS
  • Teri Dittrich, RDCS
  • D. Stephanie Empizo
  • Liz Enriquez
  • Julie Filler, RDCS
  • Dhammika Gamage, RDCS
  • Anthony Hadnot
  • Glenda Herrera, RN
  • Thao Q. Huynh-Covey, RDCS, Lead Sonographer, Hillcrest
  • Xi Lien, RVT
  • Karen McClure, RDCS
  • George Mesa, RDCS, Lead Sonographer, SCVC
  • Vince Miller, RDCS
  • Laura Mortensen, RDCS
  • Maria Orozco
  • Doreen Perez
  • Therese Romero, RDCS
  • Julia Schriber, RDCS
  • Kim Spencer, NP
  • Kelly Warrick

Sites

Hillcrest Heart Station Backline: (619) 543-6399 or (619) 543-6377
Fax (619) 543-2775
Hillcrest Echo Lab: (619) 543-5715

SCVC Non-invasive Backline: (858) 657-8111 or (858) 657-8118
Fax (858) 657-8996
SCVC Echo Lab: (858) 657-8905
SCVC Echo Reading Room: (858) 657-8183

Lewis St. Echo Room: (619) 471-9261
Encinitas Clinic: (760) 634-8273