Over the past 25 years, transesophageal echocardiography (TEE) has become an integral part of the care received by patients undergoing heart surgery. The interest in the perioperative application of TEE (PTE) continues to broaden and now includes, to name just a few, liver transplantation, lung transplantation, major vascular surgery, and persistent hemodynamic instability in the operating room. Anesthesiologists have been actively involved with PTE from its inception, and some degree of training in PTE has become an integral, accepted component of all anesthesiology residencies. The program requirements for anesthesiology training state that residents should have “significant experience with … the use of TEE.”1 This chapter reviews the issue of training for anesthesiologists in PTE and discusses the development of certification in this area.

One of the first publications addressing training in PTE came from the Cleveland Clinic Foundation, the largest center for heart surgery in the United States.2 The authors described an extensive training program developed for the cardiac anesthesiologists using TEE during heart surgery at their institution. The training took place over a year and started off with 6 months devoted to full-time training, initially in the echocardiography laboratory and then divided between the lab and the cardiac operating room (OR). The second 6 months consisted of closely supervised intraoperative echocardiography experience integrated with anesthesiology responsibilities. The program included extensive training and experience with transthoracic echocardiography (TTE) as well as TEE. The editorial accompanying this publication thoughtfully supported the importance of training in PTE, but pointed out the impracticality of extended, full-time training for many anesthesiologists, and advocated in favor of an “on the job” approach to training through a mentoring program with an experienced expert in PTE to be available at critical times during the procedure.3 The editorial also put forth the view that training in TTE was not the most efficient way for practitioners exclusively using TEE to be trained. Both approaches have been successfully applied in different ways at various institutions, and many TEE education programs provide a combination of intensive full-time echo lab experience with mentoring in the OR.

Perhaps the most important early document to address training and the use of TEE in the perioperative setting was the seminal Practice Guidelines for Perioperative Transesophageal Echocardiography,4 jointly developed by the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) and published in 1996. It was written by a task force formed in 1993 that was led by Daniel Thys, MD, and consisted of nine anesthesiologists, two cardiologists, and one methodologist who reviewed over 500 publications relevant to PTE. While this document focused primarily on the various indications for TEE in the perioperative setting, it did discuss training and fairly specifically defined the cognitive and technical skills needed for training in PTE at two levels, basic and advanced (Tables 26–1 and 26–2). Basic training was defined as the use of TEE in the customary practice of anesthesiology and included such applications as monitoring for myocardial ischemia, evaluation of ventricular function, and assessment of hemodynamic instability. Advanced training included using the full diagnostic potential of TEE such as quantification of cardiac valve lesions and evaluation of valve repairs and complex congenital heart defects. Subsequent PTE guidelines and certification processes have continued to refer to these cognitive and technical skills.

The next major step in the development of training and certification was the formation in 1995 of the SCA Task Force for Certification in Perioperative Transesophageal Echocardiography. This group was led by Solomon Aronson, MD, and consisted of 10 SCA members with considerable experience and expertise in TEE. Over the next 2 years, this group met regularly and developed what is now called the Examination of Special Competence in Perioperative Echocardiography (PTEeXAM). The PTEeXAM covers perioperative applications of TEE at the advanced level, and is intended primarily for anesthesiologists using TEE during cardiac surgery, although other physicians are eligible and have taken it. Early on, the task force considered whether to create certification processes at both the basic and advanced level, and after much discussion the decision was to address only the advanced level, and defer basic level certification to another time and place. Besides the cognitive and technical skills described for the advanced level in the practice guidelines, the test writers had in mind the level of knowledge in PTE that a candidate would have after completing a 1-year fellowship in cardiothoracic anesthesiology. The SCA worked with the National Board of Medical Examiners in developing the PTEeXAM to assure the quality of the examination and the certification process.

The examination was administered in a pilot form to a group of volunteers at the SCA annual meeting in 1997 in order to assess the quality of the questions and to help establish the level of knowledge, or standard, required to pass the test. The PTEeXAM was then offered for certification to interested physicians at the SCA annual meeting in 1998 and has been given every year since that time. Over 4000 physicians, the vast majority anesthesiologists, have taken it. The same level of knowledge (standard) was used to determine the passing score for the PTEeXAM through 2001 and then, because of a steadily increasing passing rate of well over 80%, a somewhat higher standard was set, essentially raising the bar, in order to keep the PTEeXAM a credible test of advanced knowledge in PTE. This new standard has been used to determine the passing score since 2002. Over the first 4 years the test was given, overall performance was positively related to having 3 or more months of training in echocardiography or performing at least six TEE examinations per week.5