Published on behalf of the European Association of Echocardiography, the Association for European Paediatric Cardiology, and the Working Group on Grown-up Congenital Heart Disease of the European Society of Cardiology

Introduction and aims

1. Accreditation will be run as a service by the Congenital Section of the European Association of Echocardiography and the Association for European Paediatric Cardiology. It is not necessarily a compulsory or regulatory certificate of competence or excellence.
2. The goals of accreditation are to protect children and adults with congenital cardiac disease from undergoing echocardiographic examinations performed by unqualified persons, and to set a European standard for competence and excellence in paediatric and grown-up congenital echocardiography.
3. Accredited paediatric and congenital echocardiographers are expected to be able to perform and report routine unsupervised echocardiographic studies in children or adults with congenital cardiac disease. Accredited echocardiographic technicians are supposed to report under the supervision of a Paediatric or Congenital Cardiologist.
4. While European Accreditation is designed to test the competency of an individual to be able to perform, interpret, and report routine congenital echocardiographic studies unsupervised, the right to report and sign clinical studies in individual countries will be defined by national laws.
5. Accreditation in paediatric and congenital echocardiography should bring credibility and professional legitimacy to an individual by demonstrating competency by the successful passage of examinations.
6. The process of accreditation will consist of a written and a practical component.
7. The process of accreditation will identify qualified practitioners of paediatric and congenital echocardiography, and should enhance their professional image. It will also provide statistics and records about paediatric and congenital echocardiography that can be easily accessed.
8. As skills in echocardiography can only be maintained by continued education and practical involvement, a process of re-accreditation process will also be required. The duration of accreditation will be five years.

Summary of process and requirements

1. Enrolment for the process of accreditation will be through the European Association of Echocardiography Accreditation Education Project Manager at the European Heart House. Is it also possible on-line though the website of the European association for Echocardiography.
2. The written assessment can be taken only after acceptance for enrolment.
3. The process of accreditation should be completed within a period of one year from the date of enrolment. During this period, both the written and the practical assessment should be completed.
4. Paediatric echocardiographers can directly apply for the paediatric accreditation. For those involved with echocardiography of grown-ups with congenital cardiac disease, it is suggested that they first pass the process of accreditation in transthoracic echocardiography before taking part in the examination for accreditation in Congenital Cardiac Disease. This explains the difference in number of studies required for the log book.
5. The practical assessment can either be completed in the 12 months following enrolment, or can consist of cases performed by the applicant in the period of 12 months prior to the date of enrolment.

The following must be submitted directly online to the webpages of the European Association of Echocardiography <www.escardio.org/EAE>:

• 750 Transthoracic reports of paediatric echocardiography, the paediatric section, or 500 studies of congenital lesions in grown-up patients, the grown-up section, along with 75 transoesophageal studies of congenital cardiac malformations. Those submitting for the paediatric section should also provide reports of 25 fetal studies. All studies should be performed and reported in the national language by the candidate. For echocardiographic technicians taking part in the process of accreditation, the reports have to be approved and signed-off by a paediatric or congenital cardiologist.
• A letter from an appropriate member of the Association for European Paediatric Cardiology, or the appropriate national body, testifying that the studies were performed and reported by the candidate (see suggested layout enclosed).
• A log book should be submitted within 12 months after the date of enrolment. Failure to do so will necessitate repeating the entire process from the beginning.
• A fee, currently set at 200 euros, will be charged for the completed process of accreditation. This fee is payable, in advance, upon enrolment and will also cover the submission of the log book. Candidates who are unsuccessful in the written section of the examination will be charged a reduced fee of 100 euros to re-sit this section.

To obtain accreditation, candidates must pass both the written and practical parts of the assessment.

Details of written and practical assessments for Accreditation in Paediatric and Congenital Echocardiography

1  Written assessment

1. 1.1  The written assessment will be held on two occasions each year. Full details of dates and venues, and registration forms, can be obtained through the Association for European Paediatric Cardiology or the European Association of Echocardiography Web site (www.escardio.org/EAE), and details can be provided by the Education Project Manager at the European Heart House.
2. 1.2  The written assessment will be sat under formal examination conditions. It will consist of two parts: a multiple choice examination and clinical cases evaluation questions.

2  Multiple choice examination

1. 2.1  This will consist of a series of multiple choice questions which must be answered within a given period of time. The questions will test the knowledge of candidates of the principles and practice of echocardiography.
2. 2.2  Each question will be comprised of a brief statement followed by 5 questions relating to the statement. Candidates are required to say whether each question is “true” or “false”; a blank response is used for “don’t know”. See example questions.
3. 2.3  There will be no fixed number of correct answers. For each question it is possible for every answer to be false or every answer to be true, or any combination of true or false.

3  Evaluation of clinical cases

1. 3.1  This will consist of a series of questions based on imaging material reflecting the range of clinical conditions seen in current echocardiographic practice. Normal or near-normal studies may also be presented.
2. 3.2  Candidates will be asked specific questions, for example, to describe the appearance of the mitral valve or the function of the mitral valve. They may be asked to state the diagnosis or to list specific signs of severity. See example questions.
3. 3.3  The total marks for each video question will vary depending on the complexity of the case and the clinical importance of the abnormalities demonstrated.

4  Passing the written assessment

1. 4.1  Both parts of the examination will be graded by an appropriate independent body.
2. 4.2  Accreditation will only be awarded once a candidate has also completed the practical assessment. A satisfactory performance at the written assessment alone does not allow “partial accreditation”.
3. 4.3  In the written assessment it will be necessary to pass both the multiple choice and clinical case evaluation questions. An appropriate pass mark for the multiple choices and for the clinical case evaluation questions will be set by the examining board.
4. 4.4  There is no bar to re-sitting the written assessment.
5. 4.5  Feedback from the examining board and from the candidates will be collected in the form of a questionnaire, to be used for improving the quality of the process.

5  Practical assessment – General

1. 5.1  The log book must be presented within 12 months of enrolment. It can include cases performed during the entire training program in congenital and paediatric echocardiography but the log book must be submitted within 12 months after completing the examination.
2. 5.2  The log book as well as the letter from the appropriate person or national body and the summary sheet should be uploaded directly online on the webpages of the European Association of Echocardiography (www.escardio.org/EAE).

6  Log book

1. 6.1  The log book should give details of 750 transthoracic cases, for those submitting for the paediatric examination, and 500 cases for those submitting for the adult congenital part, personally performed and reported by the candidate during a period of 12 months either prior or after the date of enrolment. In addition, details should be provided of 75 transoesophageal studies, and for those submitting for the paediatric section, details of 25 fetal studies.
2. 6.2  The preferred format for the log book performed in the national language is the electronic one. The reports should include cavity and Doppler measurements, objective observations, and a comment (see example at the end).
3. 6.3  The studies should reflect the normal case-load of a general paediatric and congenital echocardiography department and should include cases of:

• Assessment of ventricular function assessment
• Valvar heart disease
• Septal defects, such as ventricular or atrial septal defects
• Right heart obstructive lesions, such as tetralogy of Fallot, or pulmonary atresia
• Left heart obstructive lesions, such as coarctation, or hypoplasia of the left heart
• Discordant atrioventricular connections, or double discordance
• Discordant or double outlet ventriculo-arterial connections
• Anomalies of bodily arrangement, including isomerism
• Postoperative congenital cardiac disease.
• Suspected endocarditis
• Cardiomyopathies
• Coronary arterial anomalies, such as Kawasaki disease
• No more than one-third of the studies should be completely normal.

1. 6.4  A tally of the primary diagnosis assigned to each case must be entered on the appropriate enclosed summary sheet.
2. 6.5  If possible there should be one or more examples of unusual diagnoses. More than one candidate from the same institution is permitted to study the same patient if the diagnosis is unusual.
3. 6.6  If the candidate has problems finding enough specific cases, he/she should discuss this with his/her supervisor, who may consider arranging for the candidate to attend a larger centre.
4. 6.7  A letter from an appropriate person or national body must be submitted with the completed log book certifying that the candidate has recorded the studies her/him self.
5. 6.  For the echocardiographic technicians taking part in the process of accreditation, the reports have to approved and signed-off by a paediatric or congenital cardiologist.

Proficiency Examination: Example Multiple Choice Questions

Answer “True” (T) or “False” (F) to each of the following. Each correct answer gains one mark/point, and each incorrect answer loses one mark/point. A question left blank does not gain or lose any marks/points.

Questions:

Q1 In an ultrasound imaging system:

1. a) Sector width, sector depth and frame rate can all be controlled independently   F
2. b) Frame rate falls as sector width increases   T
3. c) Using a lower frequency transducer improves the frame rate   F
4. d) The frame rate increases as sector depth increases   F
5. e) Using colour Flow Doppler reduces the frame rate   T

Q2 On a spectral Doppler display:

1. a) The velocity at which aliasing occurs increases at higher ultrasound frequencies   F
2. b) The velocity at which aliasing occurs increases at greater depths   F
3. c) The velocity at which aliasing occurs increases at greater sector angle   F
4. d) At 2 MHz the aliasing velocity at 10 cm is approximately 1.5 m/s   T
5. e) The aliasing velocity can be increased by increasing the pulse rate (High PRF)   T

Q3 In assessing tricuspid regurgitation:

1. a) Pulmonary systolic pressure (PAP) can be calculated using the formula PAP= 4× (Peak TR Velocity)²   F
2. b) Presence of proximal flow acceleration indicates at least moderately severe TR   T
3. c) Both apical and parasternal views should be used to view the colour jet   T
4. d) In very severe (“free”) regurgitation, the calculation of pulmonary pressure is invalid   T
5. e) Additional information can be obtained from flow patterns in the SVC and IVC   T

Q4 In a patient with systemic hypertension:

1. a) Mean LV wall thicknesses are always greater than 1.1 cm   F
2. b) Peak aortic ejection velocity is increased   F
3. c) Typically the trans-mitral e-wave has reduced amplitude and increased deceleration time   T
4. d) Typically the Isovolumic Relaxation Time (IVRT) is reduced   F
5. e) The presence of mitral or aortic regurgitation indicates additional pathology   F

Q5 An atrial septal defect (ASD) may be associated with:

1. a) Paradoxical interventricular septal motion   T
2. b) No obvious defect of the atrial septum on imaging   T
3. c) Right ventricular dilation   T
4. d) Left ventricular dilation   F
5. e) Flow of blood from left atrium to right atrium   T

Example Clinical Cases Evaluation Questions and Answers

Question 1

This recording was made in a 12 year old boy with an abnormal chest radiograph discovered when she had a chest infection. The diameter of the ascending aorta was 4.4 cm.

a) Describe the aorta and the aortic valve. (7 marks possible)

Answer:

The ascending aorta is dilated (1 mark) but the diameters of the arch and descending thoracic aorta are normal (1 mark). There is a mobile echo in the lumen (1 mark) consistent with a dissection flap. On colour flow mapping a true and false lumen can be differentiated (1 mark) and an entry site can be seen just above the aortic valve (1 mark).

The aortic valve is thin and opens fully (1 mark) and there is a thin jet of regurgitation/mild regurgitation (1 mark).

b) What is the diagnosis? (2 marks possible)

Answer:

Aortic dissection (2 marks)

c) What other relevant abnormal signs might have been seen in these views? (2 marks possible)

Answer:

Pericardial effusion (2 marks) or left ventricular hypertrophy (secondary to hypertension) (1 mark) or inferior infarction (as a complication of dissection) (1 mark).

Question 2

This 18 year old man reported breathlessness on exertion.

a) Describe the obvious abnormality. (5 marks possible)

Answer:

There is a large mass in the left atrium (1 mark) of mixed echogenicity (1 mark). It is probably attached to the atrial septum (2 marks) and prolapses through the mitral valve in diastole (1 mark).

b) What is the likely diagnosis? (2 marks possible)

Answer:

Left atrial myxoma

c) What other echocardiographic view would be helpful and why? (2 marks possible)

Answer:

Subcostal (1 mark) to look for an attachment to the atrial septum (1 mark).

Question 3

The request form says “fever? cause”. The V_max of the tricuspid regurgitant signal is 3.0 m/s.

a) Describe the tricuspid valve (5 marks possible)

Answer:

There is a mass attached to the tip of the leaflets (1 mark). There is a moderate width jet of regurgitation on colour mapping (1 mark). The continuous wave signal is dense (1 mark) although there is no systolic flow reversal in the hepatic vein (1 mark). The TR velocity of 3 m/s suggests mild pulmonary hypertension (1 mark).

b) What is the likely diagnosis? (1 mark possible)

Answer:

Infective endocarditis (1 mark)

Suggested format for a Report

A report should have a section for objective M-mode or 2D dimensions and Doppler measurements. There should be a section for describing observations and usually a short conclusion.

Measurements Measurements of intracardiac dimensions can be useful in monitoring, disease progression. These can be made using M-mode or 2D and must be interpreted in the light of the size and sex of the patient. Many pragmatic normal ranges are outdated and modern data based on large populations include upper dimensions previously regarded as abnormal. Doppler measurements should be listed.

Text This should include a description of observations made in a logical order. The order will vary for the operator and the study. The most important feature might be described first. Alternatively each anatomical region might be discussed in turn. Interpretation should not be a part of this section and even minor abnormalities are best described. These can be put into context in the conclusion. It is usually not advisable to describe each modality in turn or to describe findings at each window as is sometimes done. This is confusing since small differences can emerge between different windows or repetitions occur. It is better to integrate all windows and all modalities. Normal findings should also be stated and if a region could not be imaged this should also be admitted. This gives the reader the confidence that a systematic study has been undertaken rather than a study focused on only a region of interest.

Conclusion This should summarize the whole study and be easily understood by a non-echocardiographer. It should identify any abnormality, its cause and any secondary effect. No interpretation should be offered that is not derived from the recorded study, and no medical advice should normally be given.