Accreditation in Adult

Transthoracic
Echocardiography (TTE)
information pack

This pack is for the use of all candidates undergoing the

accreditation process and becomes effective as of
Friday 1 April 2022

This document supersedes all previous versions

This document is a guide to completing BSE TTE accreditation

Submission and assessment criteria are included

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Contents
Contents............................................................................................................. 2
Welcome message from the Chair of Accreditation ............................................. 3
Introduction and aims......................................................................................... 4
Summary of process requirements ..................................................................... 4
Exam fees ........................................................................................................... 4
Extensions and appeals ....................................................................................... 5
Mentor ............................................................................................................... 5
Details of the written theory examination ........................................................... 5
Multiple-choice theory section ......................................................................... 6
Image reporting section.................................................................................... 6
Details of the practical assessment ..................................................................... 6
Logbook submission ......................................................................................... 7
Other information regarding the logbook: ........................................................ 8
Practical scanning assessment .......................................................................... 8
Viva case submission ........................................................................................ 8
Practical assessment - Outcomes and process for re-attempts .......................... 9
Appendix 1: Training syllabus ............................................................................ 11
Appendix 2: Curriculum based competency tool................................................ 29
Appendix 3: Reading list .................................................................................... 33
Appendix 4: Written examination registration guidance .................................... 34
Pre-registration (through the BSE website) ..................................................... 34
Delivery methods: Pearson VUE offer two ways of taking the exam. ................ 34
Special accommodations ................................................................................ 34
Registration (through Pearson Vue) ................................................................ 34
On the day of the exam .................................................................................. 34
Results ........................................................................................................... 35
Appendix 5: Examples of written exam multiple choice questions ..................... 36
Appendix 6: Examples of the written exam image reporting questions .............. 37
Appendix 7: BSE logbook portal user guidance .................................................. 38
Appendix 8: Logbook guidance and marking criteria .......................................... 47
Appendix 9: Guidance for the removal of patient identifiable data .................... 51
Appendix 10: Practical scanning mark scheme .................................................. 52
Appendix 11: Patient case studies viva marking criteria ..................................... 53

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Welcome message from the Chair of Accreditation

Dear candidate,

Welcome to the British Society of Echocardiography (BSE). The process underlying

accreditation is set up to assist the echocardiographer in training with the ultimate aim of
achieving and maintaining a high standard of clinical echocardiography for the benefit of our
patients.

The accreditation process is regulated to ensure a high level of proficiency and professional
standard. We aim to make it possible for as many members to achieve accreditation. A list of
accredited members is maintained on the BSE website.

Please let us know if we can assist you in this process or if you have constructive feedback to
offer to the Accreditation Committee; please contact the BSE office.

Good luck with your accreditation process.

Best wishes,

Sadie Bennett

Chair of Accreditation, British Society of Echocardiography

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Introduction and aims
▪ Accreditation is run as a service for members of the BSE and is not a compulsory or regulatory
certificate of competence or excellence.
▪ Accredited members are expected to be able to perform and report echocardiographic studies
unsupervised.
▪ The accreditation process comprises two parts: a written theory examination and a practical
assessment. Further information for both is available within this pack.
▪ Accreditation is a minimum requirement and cannot be regarded as a guarantee of
competence.
▪ Echocardiography skills can only be maintained by continued education and practical involvement
in echocardiography. The importance of this is underlined by limiting accreditation to five years,
after which re-accreditation must be sought.

Summary of process requirements

▪ The candidate must be a member of the BSE.
▪ A candidate must have a designated mentor to assist them through the accreditation process.
▪ The accreditation process has two compulsory elements: a written theory examination and a
practical assessment. Both elements need to be passed to become an accredited member.
▪ The written theory exam comprises two parts: a multiple-choice question (MCQ) theory section
and a "best answer" image reporting section.
▪ The practical assessment comprises three parts: a logbook, a practical scanning assessment and a
viva assessment of five patient case studies.
▪ The candidate must pass the written assessment before registering to attend the practical
assessment.
▪ The logbook should be collected over a period of no more than 24 months from the written
examination.
▪ Any queries regarding the accreditation process should be addressed to: BSE Accreditation
Department, contact details and registrations are available on www.bsecho.org. Tel: 0208 065
5794 (mainline open from 09:00-17:00 Mon-Fri), Email: [email protected].

Exam fees
▪ A fee of £275.00 is charged for the complete accreditation process. This fee is payable in advance
upon registration for the written section of the examination and covers the practical assessment.
There is a non-refundable booking fee of £20.00 to pay upon registering for a secured placement
at the practical assessment.
▪ Candidates who are unsuccessful in the written section of the examination will be charged a
reduced fee of £137.50 to re-sit this section. This reduced fee only applies to candidates who re-
sit the examination within two sittings of the unsuccessful attempt (i.e. within 12 months of an
unsuccessful attempt).
▪ Candidates are entitled to one re-attempt at the practical assessment. A re-attempt at the
practical assessment is subject to an additional fee of £137.50.

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Extensions and appeals
▪ Extensions to the 24-month deadline may be granted per the extensions policy. Extension
requests forms must be submitted before the submission deadline. Extension request forms
(along with all other BSE application forms) can be found at www.bsecho.org. Requests received
after the case deadline may not be granted.
▪ A non-refundable charge of £100.00 will be made for each extension request regardless of the
outcome.
▪ Candidates can appeal the decision on a practical assessment. There is no appeals process for the
written section of the examination. Further information can be accessed via www.bsecho.org.

Mentor
▪ A mentor is an experienced echocardiographer who can successfully guide a candidate through
the BSE accreditation process. If the echocardiographer is BSE accredited, this is advantageous
but not essential.
▪ The mentor should clearly understand the accreditation process, including the training syllabus
(see Appendix 1)and all relevant assessment criteria (see the remainder of this accreditation
pack).
▪ The mentor must assess the candidate's ability to undertake an echocardiogram to a proficient
level. Once a proficient level of ability is achieved, the mentor must complete the curriculum-
based competency tool and the mentor statements. These can be accessed and completed via
the online logbook portal. The curriculum-based competency tool can also be found in Appendix
2.
▪ Candidates who cannot find a mentor should contact us; we will try our best to help source a
suitable mentor.

Details of the written theory examination

▪ The full training syllabus for this accreditation process is available in Appendix 1. A recommended
reading list is available in Appendix 3.
▪ The written theory examination is held twice a year, usually in the Spring and Autumn. The
examinations are held at various Pearson VUE centres across the UK, the Republic of Ireland, and
some overseas locations. Dates and online registration are announced on the written assessment
section of the BSE website. Further information on registrations for the written examination can be
found in Appendix 4.
▪ The written examination has two parts, an multiple-choice theory section and an image reporting
section. In order to pass the written examination overall, it is necessary to pass both parts at the
same exam sitting.
▪ The pass mark for the multiple-choice theory section is 70%, and the image reporting section is
60%. These may vary slightly at the discretion of the Chair of Accreditation, following moderation.
▪ There is no bar to re-sitting the written examination any number of times.
▪ Accreditation is awarded once a candidate has also successfully completed the practical assessment.
Satisfactory performance at the written assessment alone does not allow 'partial accreditation.'

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Multiple-choice theory section
▪ Consists of 25 questions that must be answered within 60 minutes.
▪ Questions are designed to test the knowledge of echocardiographic findings, basic cardiology and
the physics of ultrasound.
▪ Each question comprises a brief statement followed by five questions. Candidates are required to
answer 'true' or 'false' to each question. Example questions are provided in Appendix 5.
▪ This part of the examination will be marked +1 for correct answers, 0 for incorrect or unanswered
questions (no negative marking).
▪ There are no 'trick' questions.
▪ There is no fixed number of correct answers, i.e. 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.
▪ The maximum possible mark is 125.

Image reporting section

▪ Consists of 50 questions centred around 10 patient case studies that must be answered within 90
minutes.
▪ The candidate will be presented with 10 patient case studies. Each case study will comprise of
relevant patient details and a variety of echocardiographic images.
▪ For each case study, the candidate will be required to answer five questions. Each question will
have four possible answers; the candidate must select the best single answer. An example case
study and questions are provided in Appendix 6.
▪ The maximum possible mark is 50.

Details of the practical assessment

▪ The practical assessment is held up to five times per year. Dates, locations and online registration
instructions are announced on the practical assessment section of the BSE website.
▪ The practical assessment has three parts, a 250 case logbook, a practical scanning assessment
and a viva assessment of five patient case studies.
▪ All candidates will be required to attend within 26 months of starting the accreditation process
(i.e. within two months of their case collection deadline). A two-month grace period is designed
to give the candidate time to review, prepare, and submit the logbook and five viva cases in
PowerPoint presentations.
▪ Registration should ONLY be sought after collecting the logbook and patient case studies.
▪ It is the candidates' responsibility to ensure they enter the correct information on registration
forms. Incorrect information will lead to a rejected registration.

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Logbook submission
▪ The logbook should demonstrate the candidate's ability to meet the competencies, as shown in
Appendix 2. The specific case mix of the logbook is shown below.
▪ It should consist of 250 reports personally performed and reported by the candidate during the
specified period of 24 months. The logbook is reduced to 150 reports if the candidate holds BSE or
EACVI TOE Accreditation. There is no reduction in the logbook numbers for candidates holding EACVI
TTE accreditation.
▪ The logbook format is copies of the actual clinical report. The reports are to be uploaded and
submitted via the BSE logbook portal. Please see the portal user guide in Appendix 7 . Non-portal
logbooks will not be accepted.
▪ For full details of what is expected in reports and how the logbook is marked, please see Appendix 8.
▪ Duplicate reports are not acceptable.
▪ If you have problems finding enough specific cases, discuss this with your mentor, who may consider
arranging for you to attend a nearby centre.
▪ The logbook should reflect the candidate's best clinical practice, and as such targeted scans, unless
showing a significant and rare pathology, should not be included.
▪ Competencies and mentor statements are to be completed via the BSE logbook portal.
▪ Fully subscribed BSE members can request access to the portal before sitting the written examination
by emailing [email protected].

The logbook should reflect the normal case-load of a general adult department with the following
constraints:
▪ At least 25 cases should be for left ventricular abnormality assessment*
▪ At least 50 cases should be for valve disease assessment**
▪ At least 10 cases should be for replacement/repaired valves
▪ At least 10 cases should be for right ventricular abnormality assessment***
▪ At least 5 cases should be for pericardial disease/effusion assessment
▪ At least 5 cases should be for abnormalities of the aorta
▪ At least 2 cases should be for confirmed endocarditis, mass or thrombus
▪ At least 5 cases should be for left ventricular hypertrophy assessment, at least 2 should be for
hypertrophic (-/+ obstructive) cardiomyopathy
▪ At least 3 cases should be for simple congenital disease (e.g. ASD, VSD, PDA, BAV)
▪ A maximum of 15 cases should be for specialised studies (i.e. bubble echo and contrast studies).
This section is not compulsory
▪ A maximum of 30 cases should be for no significant abnormality

* This section should demonstrate a candidate's ability to assess for left ventricular abnormalities (normal /
dilated cavity size, systolic impairment with global or regional wall motion abnormalities or diastolic
impairment). At least half of the reports in this section should include a biplane Simpson's ejection fraction
measurement.

** This section should demonstrate a candidate's ability to assess for all severities of valve pathology and not
primarily mild disease. The majority of these studies should consist of moderate to severe pathology.

*** This section should demonstrate a candidate's ability to assess for right ventricular abnormalities (normal
/ dilated cavity size, systolic impairment with global or regional wall motion abnormalities).

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Other information regarding the logbook:
▪ All identifiable patient data needs to be removed. This may require the manual removal of
identifiable data. See Appendix 9.
▪ At least the final 150 cases should be reported primarily by the candidate, although another
operator may check them.
▪ Logbook reports should reflect the latest BSE guidance. Where local policy deviates from this, a
supporting letter (and current standing operating procedure) from the department echo lead
stating local policy should be included. This should be submitted under the ‘optional supporting
information’ section on the BSE logbook portal.
▪ The candidante's name must appear on the report as the performing and reporting
echocardiographer/sonographer. Where local policy deviates from this, a supporting letter and
current standard operating procedure from the department Echo lead stating local policy should
be included. This should be submitted under the "optional supporting information" section on the
BSE logbook portal.
▪ The department's echo lead undertakes the final sign off validation of the logbook. Please see the
portal user guide in Appendix 7.

Practical scanning assessment

▪ Consists of a candidate acquiring up to 10 different echocardiographic imaging views within 20
minutes. A real-life model or simulator may be used.
▪ This part of the assessment is designed to assess a candidate's practical scanning ability and their
ability to perform basic image optimisation.
▪ All imaging views used in this assessment are taken from the minimum BSE transthoracic
echocardiography dataset.
▪ A pass mark/trigger score of 83 is used. Once obtained, the candidate will be deemed successful
at this part of the assessment process.
▪ The candidate is not expected to be familiar with the equipment. The assessor will alter the
equipment setting as directed by the candidate.
▪ For full details of the practical scanning marking criteria, please see Appendix 10.

Viva case submission

▪ Consists of a viva assessment of five separate patient case studies. See below for the required
cases.
▪ The candidate will be expected to discuss their patient cases with the assessor. All five cases may
be reviewed.
▪ For full details of the viva case marking criteria, please see Appendix 11.
▪ The case studies should be assessed using the most up to date BSE guidance. Candidates will be
expected to know the most up to date BSE guidance, and local deviations in practice will not be
accepted.
▪ The cases must represent a complete study that is of good quality. Cases should be accompanied
by a printed report. This should be complete, comprehensive, and reflect the presented patient
case study.

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 ▪ The candidate must ensure that at least one entire cardiac cycle is recorded. The cases must play
automatically/continuously within a PowerPoint presentation (or equivalent). Cases that do not
play appropriately may be classified as an unsuccessful attempt.
▪ Candidates must bring and present their patient case studies on their own laptop. It is the
candidate's responsibility to ensure these are anonymised and can be viewed in a manner to
allow an assessment of the cases being presented.

The viva case studies should include one of each of the following:

1. A study showing no significant abnormality.

2. Moderate or severe aortic stenosis.
3. Moderate or severe mitral or aortic regurgitation.
4. Previous or recent myocardial infarction.
5. The fifth case should show an example of one of the following (and which has not
previously been shown in the cases above):

a) Valve repair/replacement.
b) Mass or thrombus.
c) Simple congenital heart disease.
d) Significant left ventricular hypertrophy.
e) Significant pericardial effusion, mitral stenosis or right heart disease.

**Patient case studies may be used in subsequent BSE written exams, educational and training
sessions**

Practical assessment - Outcomes and process for re-attempts

▪ A candidate will have two attempts at passing the practical assessment part of the accreditation
process. A second attempt at the practical assessment is subject to a fee of £137.50.
▪ If a candidate is successful in all three parts of the practical assessment, the candidate will be
awarded BSE TTE accreditation and join the accredited member list.
▪ If a candidate is unsuccessful in any of the three parts of the practical assessment, the candidate
will be deemed to have been unsuccessful at this first attempt. The candidate will be provided with
constructive feedback to facilitate a re-attempt. See below for more details.
▪ In the event of an unsuccessful first attempt, the candidate may be requested to resubmit logbook
reports/patient case studies. These must be new reports/patient case studies. A candidate is not
permitted to resubmit previously assessed work under any circumstance.
▪ If a candidate is unsuccessful at the second attempt of the practical assessment, the accreditation
process must be started over with the candidate undertaking the written examination again.

In the event of an unsuccessful attempt, the candidate is required to:

▪ Attend another practical assessment and re-attempt ONLY the parts of the practical assessment
that the candidate was unsuccessful at in the first attempt. The pass marks from the remaining
practical assessment elements will be upheld.

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▪ The timescale allowed for re-attempts will depend on the unsuccessful elements and the
candidate's current and future work commitments. This will be discussed with the candidate during
the first attempt. Typical timeframes may include 3-9 months.

Our feedback consistently demonstrates that non-face to face feedback does not adequately equip a
candidate to pass at the next sitting. Therefore, all re-attempts at the practical assessment require the
candidate's attendance in-person to facilitate adequate and helpful face-to-face feedback*.

*Subject to government guidance, we may authorise virtual submissions.

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Appendix 1: Training syllabus
The following sections form the minimum suggested training syllabus for this accreditation process.
Candidates should use this as a guide to prepare for the written and practical assessments of this accreditation
process.

1. General concepts

1.1 The place of echocardiography

• Information that echocardiography can, and cannot provide
• 'Ruling out' pathology (sensitivity, specificity and Baye's theorem)
• Likelihood of findings influencing patient management
• Undesirable outcomes: inaction while waiting for results, clinical 'red herrings'
• Indications for echocardiography
• Competing and complementary technology
• Cardiac catheterisation (ventriculography and coronary angiography)
• C-T imaging
• Magnetic resonance imaging
• Nuclear cardiology

1.2 Service provision

• Considerations of physiologist-led versus physician-led service
• Costs: fixed and variable
• Provision and indication for specialised techniques, e.g. TOE, stress echo, contrast echo
• Availability and access
• Controlling workload
• Training and motivation of staff
• Audit, quality control, clinical governance
• Infection control

1.3 Relationship with patients

• Explaining the procedure in terms relevant to the particular patient
• Respect for patients' dignity and cultural backgrounds
• Relationships with colleagues
• Handling requests for information about the study findings

1.4 Reporting and documentation

• Standard methods and terminology

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• Distinction between technical and clinical reports
• Responsibility for reporting - medico-legal considerations (Data Protection Act)

2 Clinical role of echocardiography

2.1 Imaging physics and instrumentation
• Concepts and terminology
• Concepts of compression waves
• Definitions: frequency, wavelength, propagation velocity, amplitude?
• Units of measurement: Hz and MHz
• Decibel comparison of ultrasound with audible sound.

2.2 Propagation of ultrasound through tissues

• Speed of sound in different body tissues
• Frequency range used for diagnostic imaging
• Distinction between specular reflection and backscatter
• Principles of attenuation and scattering

2.3 Ultrasound transducers

• Piezo-electric effect
• General concepts of 2D and 3D transducer construction
• Characteristics of the ultrasound beam: Far (Fraunhofer) and near (Fresnel) zones, side lobes
• Beam steering methods: mechanical and electronic
• Focusing methods, including dynamic receive focusing
• Focus position and use of dual focus
• The role of intracardiac echocardiography

2.4 Imaging physics

• Factors affecting choice of imaging frequency: typical practical values for adults and children
• Broad-band imaging
• Harmonic imaging and M mode methods
• Curved anatomical M mode
• Scanning speed limitations, relationships between pulse repetition frequency, frame rate, scan
lines per frame, field of view, depth to be imaged
• Concept of parallel processing and its influence on frame rate and image quality
• Effect on evaluation of rapid motion
• Temporal resolution

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• Greyscale and dynamic range
• Measurement and optimisation of resolution: axial, azimuthal and elevation
• Lateral resolution and side-lobe/grating artefacts
• Reverberation artefacts
• Limiting factors for detecting small targets

2.5 Echo instrumentation

• Function of machine controls: transmit power; overall gain; time gain compensation; reject,
logarithmic compression, signal processing, dynamic range, pre-processing; post-processing
• Optimisation of imaging parameters, including transducer frequency, scan angle, gamma
correction, spatial and temporal smoothing
• Optimisation of 3D volume acquisitions, including frame/volume rate, cropping and manipulation
of viewing plane
• The advantages of 3D echocardiography over 2D echocardiography, e.g. appreciation of mitral
valve pathology, elimination of geometric assumptions in cardiac chamber volume estimations

2.6 Optimising images

• Use of gel (infection risk from transducer, operator)
• Positioning of the subject
• Standard views: Parasternal, apical (4, 5 and 2-chamber, long axis), subcostal, suprasternal, right
parasternal, long and short axis.
• Use of non-standard views
• Adapting for subjects with difficult echo windows, ventilated patients, ward-based studies,
emergency room studies

2.7 Storage and display of Images

• Basic concept of digital acquisition and storage systems. Scan converters and digital memories
• Display devices and controls, recording techniques
• Basic understanding of digital image processing and recording methods: pixel density, volume of
data, the DICOM standard, concept of data compression (JPEG, AVI, etc.) archiving of
echocardiographic studies on magneto-optical discs, CD/DVD, portable solid-state memories, ECG-
gated acquisitions vs. continuous recording, facility to review acquired loop prior to storage, facility
to choose the number and type of cardiac cycles to be recorded, facility for offline image
properties adjustment and further quantitative analysis.

3 Doppler physics and fluid dynamics

3.1 Basic fluid dynamics
• Fluid flow: significance of peak and mean velocities
• Determination of volumetric flow, continuity equation

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• Laminar and turbulent flow: Reynolds' equation (qualitative)
• Transition from laminar to turbulent flow: inlet jet Bernoulli equation
• Bernoulli principle for fluid dynamics – relationship of fluid speed and statics pressure/potential
energy
• Coanda effect

3.2 Principles of doppler

• Interaction of ultrasound waves with moving blood: The Doppler effect
• The Doppler equation: factors influencing magnitude of Doppler shift
• Spectral analysis: fast Fourier transform (qualitative)
• The spectral Doppler display: determination of mean, modal and peak velocities
• Limitation of CW Doppler caused by lack of depth discrimination
• Audible range of Doppler shift frequencies
• The effect of beam angle errors on Doppler velocities
• Aliasing: how it is caused and how it manifests in practice: the Nyquist limit
• Influence on aliasing of: transducer frequency; sample depth (range x velocity product); and beam
angle
• High pulse repetition frequency (extended range) PW Doppler and the phenomenon of range
ambiguity
• Relative advantages and disadvantages of CW, PW and HPRF modes
• Concept of colour flow imaging as multi-sampled PW
• Velocity estimation, by moving target indication and autocorrelation (qualitative)
• Limitations of mean velocity: use of velocity variance to show high velocities/turbulence
• Aliasing in colour Doppler and the effect of scan frequency on the Nyquist limit
• The principles of pulse wave tissue Doppler
• Packet size, colour mode and sector size and their effect on frame rate and aliasing

4 Deformation analysis
4.1 Principles of myocardial deformation
• The definition of displacement, velocity, strain and strain rate
• The cardiac ultrasound co-ordinate system for describing motion and deformation: longitudinal,
radial, circumferential and rotational axes
• Quantifying myocardial deformation as opposed to velocity or displacement
• Concept of shear deformation; rotation of the base and apex of the left ventricle, and the resultant
twisting deformation or torsion

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4.2 Quantifying myocardial strain and strain rate by tissue doppler
• The concept of the myocardial velocity gradient
• The concept of strain and strain rate to define deformation
• Tissue Doppler imaging for deriving strain and strain rate: practical parameters in measuring strain
and strain rate (e.g. sample size and shape, offset distance, drift compensation, spatial and
temporal averaging, tracking of sample volume)
• Reproducibility issues

4.3 Speckle tracking echocardiography/2D strain

• Familiarity with the concept of speckles and speckle tracking in greyscale 2D loops
• Speckle tracking for angle-independent derivation of velocities, displacement, strain and strain rate
• The impact of frame rates on the quality of speckle tracking
• Speckle tracking vs tissue Doppler techniques for assessing myocardial motion and deformation
• Speckle tracking for measuring left ventricular rotation and torsion
• Kindred technologies

5 Doppler instrumentation
5.1 Spectral doppler instrumentation
• Duplex Doppler using imaging transducers
• The 'Stand-alone' Doppler probe
• Features of the spectral display: positive and negative velocities; scale and baseline controls.
• Effect of high-and low-pass filter and intensity threshold ('reject') settings
• Pulsed Doppler sample volume: influence of gate length and distance (beam width)
• Representation of signal strength by image intensity
• How aliasing manifests on the spectral display.

5.2 Colour Flow instrumentation

• The colour display: BART convention
• Colour maps to show velocity scales
• Image domination and additive colour modes
• Difference between velocity and power (signal amplitude) displays
• Basic principles of tissue Doppler imaging, including optimisation of filters for detecting tissue
versus blood velocities, sample volume and size, impact of interrogation angle on measured
velocities, minimising aliasing, and maximising frame rates to detect short duration myocardial
motion
• Differences between colour Doppler tissue, Doppler imaging and pulsed wave tissue Doppler
imaging

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• Minimisation of myocardial translational movements during acquisition.
• The concept of tracking on colour Doppler tissue, Doppler imaging to ensure that sample volume
remains in the region of interest
• Parametric (curved M-mode) display of tissue Doppler images
• The relevance of importing cardiac cycle time points, such as aortic valve closure, into tissue
Doppler traces

6 TOE instrumentation
6.1 General concepts
• Transducer types: single plane, biplane, multiplane
• Optimising machine settings for TOE Patient
• Monitoring for TOE and general safety considerations
• Control of infection
• General indications and recognition of the limitations of TTE

7 Safety of ultrasound
• Potential hazardous biological effects: heating, resonance and cavitation effects
• Measurement of beam intensity (SPTA)
• Practical precautions: power levels, use of colour and CW Doppler

8 Cardiac anatomy and physiology

8.1 Anatomy of the thorax
• Thorax contained by rib cage and diaphragm
• Lungs and pleura; heart and pericardium; mediastinum
• Blood vessels within the thorax

8.2 Gross anatomy of the heart

• Basic cardiac embryology
• Nomenclature of chambers and valves
• Major relationships of chambers, valves and blood vessels
• Distinguishing features of valves and chambers as related to echocardiography
• The pericardial sac

8.3 Cardiac anatomy and physiology as demonstrated by echocardiography

• Detailed structural anatomy of the heart, great vessels and pericardium
• Visualisation of normal cardiac anatomy and normal variants in standard echocardiographic planes

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• 2D/3D, M-mode and Doppler features of normal valve anatomy (aortic, mitral, tricuspid and
pulmonary), function and normal variants
• The phases of atrial function: reservoir, conduit and contractile phases
• The LV remodelling process in response to disease: eccentric (chronically elevated preload) vs.
concentric hypertrophy (chronically elevated afterload)

8.4 The Cardiac Cycle

• Temporal relationships of the ECG, chamber pressures and valve movements
• Typical values for intracardiac pressures
• Relationship of valve movements to heart sounds
• Identification of valve opening and closure signals on Doppler recordings
• The timing of aortic valve closure as a marker of end-ejection, as derived from M- mode, blood
flow Doppler or tissue Doppler

9 Cardiac functional parameters

9.1 Measurements and calculations
• On-screen measurement of length, slope, area, volume and time interval and their
significance for 2-D, 3D images, M-mode and spectral Doppler displays
• Knowledge, appreciation and limitations of M-mode measurements (including MAPSE and
TAPSE, Ao/LA dimensions)
• Derivation of stroke volume, ejection fraction, relative wall thickness, LV Mass and indexed
LV mass
• 2D/3D methods of measuring LV volume
• Limitations of single plane estimations of LV ejection fraction e.g. Teicholtz formula method
• Limitations of single plane measurements of LA size
• Geometric assumptions used in estimation of cardiac chamber volumes with M-mode and
2D imaging
• The advantages of deriving volumes and ejection fraction by 3D echocardiography
• Limitations of measurement and/or calculation validity in the presence of poor quality
and/or off-axis images

9.1 Doppler determination of cardiac output, ejection time, valve function and velocity
acceleration
• Methods for assessing normal valve function (aortic, mitral, tricuspid and pulmonary) to
include: peak and mean velocities, peak and mean gradients, pressure half time and flow
rate assessments (where appropriate)
• Methods of measuring diastolic function: E/A ratio, deceleration time, pulmonary venous
flow patterns, the ratio of the peak early diastolic transmitral velocity and the peak early
diastolic tissue velocity of the mitral valve annulus (the E/E' or E/Ea) ratio methods for
estimating LV filling pressures, mitral valve propagation velocity

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• Peak and mean pressure gradient measurements by Doppler and their relationship to
catheterisation data
• Measurement of pulmonary pressures from tricuspid and pulmonary regurgitant flow
velocities and assessment of inferior vena cava contraction during inspiration

10 Contrast and bubble contrast studies

10.1 Bubble contrast studies
• Main indications for a bubble contrast study: Diagnosis of intracardiac shunts, diagnosis of intra-
pulmonary shunts, improved assessment of tricuspid regurgitation velocities
• Technique for performing a hand-agitated contrast bubble study
• Acoustic views required and optimisation of machine control settings for bubble contrast studies
• Patient manoeuvres to provoke right-to-left passage of bubbles during assessment for PFO
• Knowledge of findings consistent with a positive and negative intra-cardiac and intra-pulmonary
shunt.
• Relevance of injecting bubble contrast through upper arm vein vs. femoral vein
• Technique for performing a hand-agitated contrast study
• Contra-indications and clinical precautions

10.2 Awareness of encapsulated contrast agents and techniques

• Knowledge of available contrast agents
• Knowledge of contrast agent's characteristics including interaction of ultrasound
• Generation of harmonic energy by bubble distortion and fracture
• Optimisation of machine control settings for contrast agents
• Indications for administration of contrast agents to include: Enhancing endocardial definition for
assessment of regional contractility and accurate cardiac volume estimations, detection of intracardiac
masses, distinguishing thrombus from a vascular tumour, diagnosis of cardiomyopathies (e.g. non-
compaction), arrhythmogenic right ventricular dysplasia, myocardial perfusion assessment.
• Use of contrast in stress echocardiography for improving detection of wall motion abnormalities and
for assessment of myocardial perfusion
• Appreciation of contrast administration – bolus vs infusion
• Contra-indications and clinical precautions

Valve pathology
11 Mitral valve disease
11.1 Mitral Stenosis
• Aetiologies and typical 2D/3D echocardiographic features: rheumatic, calcific, myxoma/tumours,
cor-triatriatum, congenital
• Qualitative description of valve and sub-valve calcification and fibrosis

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• Assessment of mitral stenosis severity to include: mean gradient, planimetry (2D and 3D), pressure
half time method, continuity equation, PISA method: techniques and limitations
• Factors favouring successful balloon valvuloplasty: Wilkins score
• Role of exercise stress echocardiography to evaluate for changes in mean trans-mitral gradient, PA
systolic pressures, exercise tolerance and symptomatic status with exercise to aid in the timing of
surgery/balloon valvuloplasty
• Role of echocardiography in assessment and follow-up

11.2 Mitral regurgitation

• Aetiologies and typical 2D/3D echocardiographic features of primary mitral regurgitation: mitral
valve prolapse (fibro-elastic deficiency, myxomatous mitral valve, flail leaflet, Barlow's disease),
ruptured chordae, infective endocarditis, mitral annular calcification, rheumatic, congenital causes,
drug and/or radiotherapy induced
• Aetiologies and typical 2D/3D echocardiographic features of secondary mitral regurgitation:
Ischemia and impairment/dysfunction of sub-valvular apparatus (i.e. papillary muscle dysfunction
or rupture), LV dilatation, leaflet tethering, LA dilatation, annular dilatation
• Chronis vs acute mitral regurgitation and differential diagnosis
• Awareness of Carpentier classification
• Consequences of mitral regurgitation on left and right heart chamber sizes and right heart pressure
• Assessment of mitral regurgitation severity to include: vena contracta, PISA (2D and 3D), effective
regurgitant orifice area, regurgitation volume, regurgitation fraction, MV VTI/AV VTI, increased
antegrade E wave velocity and shape and density of contour of Doppler signal: techniques and
limitations
• Pulmonary vein flow patterns seen in all mitral regurgitation severity ranges: techniques and
limitations
• Role of echocardiography in determining timing of surgery for primary mitral valve disease:
ejection fraction, end-systolic LV diameter, EROA, resting PA pressure.
• Role of TOE in assessing mitral valve pathology and in determining likelihood of repair as opposed
to replacement
• Role of exercise stress echo to evaluate for MR severity changes, LV function assessment, PA
systolic pressures, symptomatic status and exercise tolerance during exercise to aid in the timing of
surgical intervention
• Role of echocardiography in assessment and follow-up

12 Aortic valve disease

12.1 Aortic stenosis
• Aetiologies and typical 2D/3D echocardiographic features of aortic stenosis: rheumatic, bicuspid
(and classification of type), senile degenerative, sub-and supra-valve obstruction
• Assessment of aortic stenosis severity to include: maximum velocity, mean gradient, aortic valve
area by continuity equation (including indexed values), valve planimetry, dimensionless index:
techniques and limitations.
• Consequences of aortic stenosis on cardiac chamber size and function

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• Appreciation of the causes of discordant parameters when assessing aortic stenosis and potential
remedies
• Use of apical, right parasternal and suprasternal positions to obtain optimal AV Doppler
parameters.
• Definition of low flow low gradient severe aortic stenosis
• Concept of flow-rate and effect on transvalvular velocities
• Use of stress echocardiography for distinguishing pseudo severe stenosis vs truly severe stenosis in
low flow aortic stenosis
• Use of stress echocardiography in patients with low flow low gradient severe AS and assessing for
LV contractile reserve
• Difference between transaortic pressure gradients derived from echocardiography and from
cardiac catheterisation
• Role of echocardiography in assessment and follow-up

12.2 Aortic Regurgitation

• Aetiologies and typical 2D/3D echocardiographic features of aortic regurgitation: rheumatic,
bicuspid, aortic root disease, infective endocarditis (including root abscesses)
• Assessment of aortic regurgitation severity to include: Colour Doppler – size of jet relative to left
ventricular outflow tract diameter, vena contracta, effective regurgitant orifice area, regurgitant
volume, diastolic flow reversal in descending aorta, diastolic flow reversal in the abdominal aorta
(including BP pulse pressure width), indirect effects on LV size and function: techniques and
limitations
• Consequences of aortic regurgitation on cardiac chamber size and function
• Role of echo in determining timing of surgery
• Role of TOE in assessing aetiology and severity
• Role of echocardiography in assessment and follow-up

13 Tricuspid valve disease

13.1 Tricuspid stenosis
• Aetiologies and typical 2D/3D echocardiographic features of tricuspid stenosis: rheumatic,
prolapse, congenital, infective endocarditis, carcinoid, functional
• Assessment of tricuspid stenosis severity to include: Mean pressure gradient, inflow velocity-time
integral, pressure half time and valve area by continuity equation techniques and limitations
• Consequences of tricuspid stenosis on cardiac chamber size and function
• Role of echocardiography in assessment and follow-up

13.2 Tricuspid regurgitation

• Aetiologies and typical 2D/3D echocardiographic features of tricuspid regurgitation: rheumatic,
prolapse, congenital, infective endocarditis, carcinoid, functional /secondary (RA, RV, annular
dilatation), trauma and device leads

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• Assessment of tricuspid regurgitation severity to include: Colour Doppler – shape and density of
continuous Doppler signal, effective orifice area, regurgitation volume (by PISA), colour flow area,
PISA, vena contracta, tricuspid inflow, colour Doppler signal, hepatic vein flow pattern, indirect
effects on RA, RV, IVC and intraventricular septal motion: techniques and limitations
• Consequences of tricuspid regurgitation on cardiac chamber size and function
• Role of echocardiography in assessment and follow-up

14 Pulmonary valve disease

14.1 Pulmonary stenosis
• Aetiologies and typical 2D/3D echocardiographic features of pulmonary stenosis: rheumatic,
congenital, infective endocarditis, carcinoid, sub-valvular and supra-valvular obstruction,
infundibular obstruction
• Assessment of pulmonary stenosis severity to include: peak velocity, peak gradient: techniques and
limitations
• Consequences of pulmonary stenosis on cardiac chamber size and function
• Role of echocardiography in assessment and follow-up

14.2 Pulmonary regurgitation

• Aetiologies and typical 2D/3D echocardiographic features of pulmonary regurgitation: congenital,
endocarditis, carcinoid, rheumatic, secondary (post valvuloplasty, post TOF repair)
• Assessment of pulmonary regurgitation severity to include: jet width percentage of RVOT, vena
contracta percentage of pulmonary valve annulus, deceleration time, pressure half time, 3D vena
contracta, Doppler pulmonary regurgitation index, origin of PR jet in relation to pulmonary artery
bifurcation: techniques and limitations
• Consequences of pulmonary regurgitation on cardiac chamber size and function
• Role of echocardiography in assessment and follow-up

15 Infective endocarditis
• Typical bacteraemia/fungal causes of infective and non-infective endocarditis
• Use of Duke criteria for infective endocarditis
• Typical 2D/3D echocardiographic features of vegetations for bacteraemia/fungal causes of infective
and non-infective endocarditis
• Typical and atypical locations of vegetations
• Complications of endocarditis to include: abscess, fistula, perforation, valve destruction and
regurgitation, prosthetic valve dehiscence, new paravalvular regurgitation, healed/ chronic
vegetations
• Infective and non-infective endocarditis associated with congenital heart disease and hypertrophic
cardiomyopathy
• Role of TOE in suspected endocarditis
• Role of echocardiography in assessment and follow-up

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16 Prosthetic heart valves
• Typical 2D/3D, M-mode and Doppler features of the main types of replacement/repaired valves to
include: Mechanical (tilting disc, bilealfet and ball and cage), bio-prosthese (stented and stentless),
leaflet repair ± annuloplasty rings, percutaneous valve intervention (mitral clip and TAVI).
• Assessment of age related deterioration of bioprostheses
• Assessment of artefacts, pannus, thrombus and vegetations (and associated complications) on
prosthetic valves
• Role of TOE in examining normal and malfunctioning prosthetic valves
• Assessment of prosthetic valve stenosis to include: 2D, M-mode and Doppler assessment, use of
continuity equation and indexed values, the phenomenon of pressure recovery
• The assessment of normal and abnormal aortic prosthetic valve function and differentiation
between high flow states, patient-prosthesis mismatch and insignificant/significant stenosis. To
include the use of maximum velocity, acceleration time: techniques and limitations
• The assessment of normal and abnormal mitral prosthetic valve function and differentiation
between normal, possible and significant prosthetic stenosis. To include: peak velocity, mean
gradient, VTi, effective orifice area and pressure half time: techniques and limitations
• The assessment of normal and abnormal tricuspid prosthetic valve function. To include: mean
gradient, pressure half time, tricuspid valve E velocity, VTi: techniques and limitations
• The assessment of normal and abnormal pulmonary prosthetic valve function. To include: mean
gradient, peak velocity: techniques and limitations: techniques and limitations
• Assessment of consequences of prosthetic valve dysfunction, to include: chamber dilatation,
progression to pulmonary hypertension
• Assessment of prosthetic valve regurgitation to include: trans-versus para-valvar regurgitation,
normal versus abnormal prosthetic valve regurgitation, assessment by CW, PW and Colour Doppler
techniques and limitations
• Role of echocardiography in assessment and follow-up

17. Cardiomyopathies
17.1 Dilated cardiomyopathy
• Aetiologies and typical 2D/3D echocardiographic features of dilated cardiomyopathies
• Detection and assessment of associated lesions to include: functional valve regurgitation,
thrombus in cardiac chambers, pericardial effusions, pulmonary hypertension
• Role of echocardiography in assessment and follow-up

17.2 Hypertrophic cardiomyopathies

• Aetiologies and typical 2D/3D echocardiographic features of hypertrophic cardiomyopathies
• Techniques for measurement of left ventricular wall thickness, detection of left ventricular outflow
tract obstruction and intracavity gradient (including the use of breath-hold and provocative
manoeuvres to assist in the detection of inducible gradients)
• Assessment of right ventricular involvement

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• Associated abnormalities to include: systolic anterior motion mitral valve and associated mitral
regurgitation, apical aneurysms and associated thrombus, abnormal papillary muscle location
• Differentiation from other causes of hypertrophy, e.g. hypertension, athletic heart, amyloidosis,
Fabry's disease, Friedreich's ataxia cardiomyopathy
• Role of echocardiography in assessment and follow-up

17.3 Restrictive cardiomyopathy

• Aetiologies and typical 2D/3D echocardiographic features of restrictive cardiomyopathies: storage/
infiltrative disorders (e.g. Fabry's, Danon disease and Friedrich ataxia), amyloidosis, sarcoidosis,
idiopathic, endomyocardial fibrosis, carcinoid heart disease, radiation or drug induced
• Assessment of restrictive cardiomyopathies to include: 2D findings, Doppler and TDI features
(small to normal LV cavity size, normal wall thickness, normal or near normal LVEF, reduced GLS,
associated GLS patterns, dilated atria, increased E/A ratio, reduced deceleration time, reduced
early diastolic velocities, increased E/E' ratio, reduced S velocities)

18 LV non-compaction
• Aetiology and typical 2D/3D echocardiographic features of LV non-compaction
• Assessment of LV non-compaction to include: Visual assessment of prominent LV trabeculation and
deep recesses. Non-compacted:compacted wall ratio of >2:1, colour Doppler flow within deep
recesses, global LV systolic function assessment, thrombus assessment, abnormal papillary muscle
structure
• Role of contrast agents

19 Intra-cardiac masses
• Aetiology and typical 2D/3D echocardiographic features and locations of masses to include:
thrombus, cardiac tumours (primary and secondary) and myxoma.
• Differentiation of myxoma from other cardiac tumours
• Features suggestive of malignancy
• Role of TOE in assessment of intracardiac masses
• Role of contrast in the assessment of intracardiac masses

20 Pericardium and pericardial pathology

20.1 Pericardium
• Anatomy of the normal pericardium
• Relationships of serous pericardium to heart and great vessels
• Transverse and oblique sinuses of the pericardium

20.2 Echocardiographic features of pericardial fluid

• Location of fluid in relation to patient position and fluid volume

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• Differentiation from pleural effusion
• Assessment of volume of pericardial fluid
• Role of echocardiography in pericardiocentesis

20.3 Features of tamponade

• Collapse of RA and/or RV walls
• Effect on IVC and hepatic vein flow pattern
• Effect on A-V valve flow velocities during respiratory cycle

20.4 Features of pericardial constriction

• Pericardial thickening/appearance
• Effect on A-V valve flow velocities
• Effect of respiration

21 Coronary artery disease and LV systolic function

• Assessment of global LV systolic function to include: 2D/3D, M-mode and Doppler indices,
Simpson's biplane ejection fraction, stroke distance, stroke volume, stroke volume index and
cardiac output.
• Use of tissue Doppler and speckle tracking echocardiography for assessment of regional
• myocardial velocities and deformation in ischaemic heart disease, at rest and with stress
• Longitudinal function of the left ventricle, as assessed by M-mode (MAPSE), tissue Doppler of the
mitral valve annulus and global longitudinal strain analysis
• The concept of post-systolic contraction
• The concept of isovolumic acceleration by tissue Doppler
• Left ventricular torsion and its implications for systolic function of the LV
• Appreciation of assessing for cardiotoxic effects of cancer therapy and the impact of LV systolic
function

22 Diastolic function of the left ventricle

• The 4 stages of diastolic function as assessed by transmitral flow Doppler, deceleration time, E':
techniques and limitations
• Doppler for assessing diastolic dysfunction: effect of LA size
• Pressures and pseudo-normalisation, effect of mitral regurgitation
• The use of Valsalva manoeuvre in reducing LA pressures to differentiate normal from
• pseudonormal transmitral Doppler patterns
• The use of left atrial size, IVRT, tissue Doppler (diastolic longitudinal velocities of the mitral valve
annulus, the E/E' ratio), pulmonary vein flow pattern and mitral propagation velocity for assessing
diastolic function

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• The importance of untwisting in left ventricular filling
• Assessment and knowledge of LA strain (reservoir)

23 Left ventricular dyssynchrony and assessment by echocardiography

• Techniques for measuring interventricular and intraventricular dyssynchrony for predicting
response to cardiac resynchronisation treatment
• Tissue Doppler quantitation of intraventricular dyssynchrony and their limitations
• Techniques for optimising settings of the cardiac resynchronisation device after implantation

24 Stress echocardiography
• Indications and basic knowledge of techniques for exercise, dobutamine or vasodilator stress
echocardiography
• Exercise or pharmacological stress echocardiography for diagnosis of ischaemic heart disease and
myocardial viability
• The concept of viable and hibernating myocardium, and the relevance of the various responses of
the myocardium to stress
• The concept of contractile reserve and flow reserve (for AS)
• The American Society of Echocardiography regional wall motion scoring system
• Dobutamine stress echo in 'low flow' aortic stenosis
• Exercise stress echo in valvular heart disease and pulmonary hypertension

25 Myocardial Infarction and its sequelae

• Ability to assess for regional wall motion abnormalities (hypokinesia, akinesia and dyskinesia) and
global LV systolic function/impairment
• Knowledge of 2D, M-mode and Doppler features of MI complications to include: post-infarction
VSD, mitral papillary muscle rupture, cardiac tamponade, mural thrombus, myocardial scarring,
Dressler's syndrome, left ventricular aneurysm (true aneurysm vs. pseudoaneurysm)
• Assessment of the main features of stress-induced (takotsubo) cardiomyopathy as a deferential
diagnosis to acute myocardial infraction

26 Pulmonary hypertension and functional assessment of right ventricle

• Aetiologies of pulmonary hypertension to include: primary, post pulmonary embolism, lung
disease, connective tissue disease and secondary to left-sided lesions
• Assessment of pulmonary hypertension by 2-D, M-mode and Doppler features of pulmonary
hypertension
• Assessment of regional and global RV systolic function to include: TAPSE, RV S velocity, fractional
area change of the RV, RV free wall 2D global longitudinal strain.
• Assessment of right ventricular dysfunction in acute pulmonary embolism (McConnell's sign and
60/60 sign) and chronic pulmonary embolism

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27 Diseases of the aorta
• Assessment of the aortic root (sinuses of valsalva and ST junction), proximal ascending, aortic arch,
descending thoracic aorta and abdominal aorta by 2-D, M-mode and Doppler.
• Assessment of Marfan syndrome, sinus of Valsalva aneurysm, thoracic aortic aneurysm, aortic
dissection (to include aortic cusp prolapse, aortic regurgitation, pericardial fluid) by 2D,M-mode
and Doppler.

28 Adult congenital heart disease

• Anatomy, pathophysiology and natural history of common congenital lesions present in adults to
include; 2-D, M-mode and Doppler features of the following (pre-operatively and post- operatively,
as seen in the older child or adult):
• Atrial septal defects (primum, secundum and sinus venous)
• Perimembranous and muscular ventricular septal defects
• Partial and complete atrio-ventricular septal defects
• Persistent ductus arteriosus
• Bicuspid aortic valve and associated aortopathy
• Sub-and supra-valve aortic stenosis
• Aortic coarctation
• Pulmonary stenosis
• Ebstein's anomaly
• Fallot's tetralogy
• Transposition and corrected transposition of the great arteries
• Role of contrast echocardiography in evaluating shunts in adults
• Calculation of shunts
• Role of TOE in adult congenital disease

29 Echocardiographic assessment of common clinical presentation of patients

• Heart failure or breathlessness
• Arrhythmia
• Ejection systolic murmur
• Hypertension
• Collagen abnormalities (including systemic sclerosis)
• Renal failure
• Stroke

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30 Emergency and ICU echo
30.1 General
• Constrained environment (multiple arterial/venous lines, ventilator, lighting issues etc)

31 The hypotensive/shocked patient and post-cardiac arrest

• Role of focused peri-arrest study and appreciation of limited echo windows
• Evaluation of LV (systolic and diastolic) and RV systolic function
• Exclusion of severe valve disease (e.g. severe AS, endocarditis) and acute aortic dissection
• Assessment for pericardial effusion and cardiac tamponade, hypovolaemia and under-filling, and
high output cardiac failure
• Septic shock – assessment of for LV systolic and diastolic function
• Value of repeated echo studies to assess any deterioration/improvement in underlying state

32 Suspected acute pulmonary embolus

• Assessment of acute pulmonary embolus to include 2D, M-mode and Doppler assessment of RV
size and function, tricuspid regurgitation and pulmonary artery systolic pressure assessment, IVC
size and respiratory variation, thrombus presence in IVC/RA

33 Blunt and penetrating cardiac trauma

• Typical echocardiographic features including pericardial effusion, right and left ventricular
contusion, acute valve lesions, aortic dilation and dissection/transection, VSD, pleural effusion

34 Echo in the ventilated patient

• Echocardiographic assessment for common clinical presentations to include 2D, M-mode and
Doppler of acute arrhythmias such as fast AF, cardiac source of embolus – CVA/peripheral embolic
event in ventilated patients
• Value of TOE in ventilated patients (if poor transthoracic echo window)

35 Post surgery patient

• Appreciation of effects of general anaesthesia and cardio-pulmonary bypass on LV function
• Assessment of post-surgery haemodynamic compromise/ acute deterioration to include: common
findings post cardiac surgery (tamponade, wall motion abnormalities and valvular dysfunction) and
general surgery (air/fat embolism, venous thromboembolism, acute MI, volume overload)

36 Assessment of filling status

• Awareness of the role of echocardiography in assessing filling using LV and RV systolic and diastolic
function, IVC, SVC and hepatic vein size and reactivity, atrial septal motion, chamber sizes and
variation in Doppler velocities.
• Role of repeated echo studies in assessing effects of fluid challenge and inotropes

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37 Additional topics
The level of knowledge expected is that of a competent echocardiographer performing transthoracic
studies and sustaining knowledge through the BSE and other educational resources, including issues
relevant to clinical scanning and practice raised in the ECHO journal

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Appendix 2: Curriculum based competency tool
The following competency assessment tool should be used to ensure all knowledge and practical experience is
covered during the candidates training period.

The competency tool is now required to be completed by the candidates mentor via the BSE online logbook
portal.

Competency Date
achieved
1. BASIC ECHOCARDIOGRAPHY
Knowledge
Basic principles of ultrasound
Basic principles of spectral Doppler
Basic principles of colour flow Doppler
Basic instrumentation
Ethics and sensitivities of patient care
Basic anatomy of the heart
Basic echocardiographic scan planes
Parasternal long axis standard, RV inflow, RV outflow
Parasternal short axis including aortic valve, mitral valve and papillary muscles
Apical views, 4- and 5-chamber, 2-chamber and long-axis
Subcostal and suprasternal views
Indications for transthoracic and transoesophageal echocardiography
Normal variants and artefacts

Practical competencies
Interacts appropriately with patients
Understands basic instrumentation
Cares for machine appropriately
Can obtain standard views
Can optimise gain setting, sector width, depth, harmonics, focus, sweep speed,
Doppler baseline and scale, colour gain
Can obtain appropriate images and undertake accurate measurements
Can recognise normal variants – Eustachian valve, chiari work, LV tendon
Can use colour examination in at least two planes for all valves optimising gain and
box-size

Can obtain pulsed wave Doppler at:

a. left ventricular inflow (mitral valve)
b. left ventricular outflow tract (LVOT)
c. right ventricular inflow (tricuspid valve)
d. right ventricular outflow tract, pulmonary valve and main pulmonary artery

2.LEFT VENTRICLE
Knowledge
Coronary anatomy and correlation with 2D views of left ventricle
Segmentation of the left ventricle for regional wall motion assessment
Measurements of global systolic function (LVOT VTI, stroke volume, fractional
shortening, ejection fraction using Simpson's rule, S velocities)
Doppler mitral valve filling patterns and normal range

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Appearance of complications after myocardial infarction:
a. Aneurysm, pseudoaneurysm
b. Ventricular septal rupture and papillary muscle rupture
c. Ischaemic mitral regurgitation

Features of dilated, and hypertrophic cardiomyopathy

Common differential diagnosis
Athletic heart, hypertensive disease

Practical competencies
Can differentiate normal from abnormal LV systolic function
Can recognise large wall motion abnormalities
Can describe wall motion abnormalities and myocardial segments
Can obtain basic measures of systolic function VTI, FS, LVEF, S velocities
Understands and can differentiate diastolic filling patterns
Can detect and recognise complications after myocardial infarction
Can recognise features associated with dilated cardiomyopathy
Can recognise features associated with hypertrophic cardiomyopathy
Can recognise hypertensive heart disease
Can recognise athletic heart
3. MITRAL VALVE DISEASE
Knowledge
Normal anatomy of the mitral valve and sub-valvular apparatus and their
relationship with LV function Causes of mitral stenosis and regurgitation
Ischaemic, functional, prolapse, rheumatic, endocarditis

Practical competencies
Can recognise rheumatic disease
Can recognise mitral prolapse
Can recognise functional mitral regurgitation
Can assess mitral stenosis
2D planimetry, pressure half-time, gradient
Can assess severity of regurgitation, chamber size, signal density, proximal flow
acceleration and vena contracta
4. AORTIC VALVE DISEASE and AORTA
Knowledge 8
Causes of aortic valve disease
Causes of aortic disease
Methods of assessment of aortic stenosis and regurgitation
Basic criteria for surgery to understand reasons for making measurements

Practical competencies
Can recognise bicuspid, rheumatic, and degenerative disease
Can recognise a significantly stenotic aortic valve
Can derive peak and mean gradients using continuous wave Doppler
Can measure valve area using the continuity equation
Can recognise severe aortic regurgitation
Can recognise dilatation of the ascending aorta
Knows the echocardiographic signs of dissection
5. RIGHT HEART
Knowledge

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Causes of tricuspid and pulmonary valve disease
Causes of right ventricular dysfunction
Causes of pulmonary hypertension
The imaging features of pulmonary hypertension
The estimation of pulmonary pressures/probability of pulmonary hypertension

Practical competencies
Recognises right ventricular dilatation
Can estimate PA systolic pressure/probability of pulmonary hypertension
Can estimate right atrial pressure from the appearance of the IVC
6. REPLACEMENT/REPAIRED HEART VALVES
Knowledge
Types of valve replacement/repair
Criteria of normality
Signs of failure
Practical competencies
Can recognise broad types of replacement valve
Can recognise repaired valves
Can recognise para-prosthetic regurgitation
Can recognise prosthetic/repaired obstruction
7. INFECTIVE ENDOCARDITIS
Knowledge
Duke criteria for diagnosing endocarditis
Echocardiographic features of endocarditis
Criteria for TOE

Practical competencies
Can recognise typical vegetations
Can recognise an abscess
Can recognise complications just on valve regurgitation
8. INTRACARDIAC MASSES
Types of mass found in the heart
Features of a mxyoma
Differentiation of atrial mass
Normal variants and artifacts

Practical competencies
Can recognise a LA myxoma
Can differentiate LV thrombus and trabeculation

9. PERICARDIAL DISEASE
Knowledge
Features of tamponade
RV collapse, effect on IVC, A-V valve flow velocities and respiratory variation
Features of pericardial constriction
Differentiation of pericardial constriction from restrictive myopathy

Practical competencies
Can differentiate a pleural and pericardial effusion
Can recognise the features of tamponade
Can judge the route for pericardiocentesis

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Can recognise restrictive physiology
Differentiation of pericardial constriction from restrictive myopathy
10. ADULT CONGENITAL HEART DISEASE
Knowledge
Anatomy and echo features of basic congenital disease:
ASD, VSD, partial and complete atrio-ventricular defects
Patent ductus arteriosus
Sub and supravalvar aortic stenosis
Sub valvar, valvar and supra-valvar pulmonary stenosis
Ebstein's anomaly
Fallot's tetralogy
Role of contrast
Estimation of pulmonary artery pressure

Practical competencies
Can recognise a secundum ASD
Can recognise a patent ductus arteriosus
Can recognise sub and supravalvar aortic stenosis
Can recognise sub valvar, valvar and supra-valvar pulmonary stenosis
Can recognise Ebstein's anomaly
Can recognise Fallots tetralogy
Can estimated pulmonary artery pressure

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Appendix 3: Reading list

The reading list is provided by the Accreditation Committee of the British Society of Echocardiography
and represents only a handful of textbooks that are available for candidate to learn from.

▪ Textbook of Clinical Echocardiography (5th edition, June 2013), ( 6th edition, May 2018) -
Catherine Otto
▪ Echocardiography Review Guide: Companion to the Textbook of Clinical Echocardiography
(3rd edition) – Catherine Otto et al. (2015)
▪ Feigenbaum's Echocardiography (7th edition) - William Armstrong and Thomas Ryan - (2010)
▪ Echocardiography: A Practical Guide for Reporting and Interpretation (3rd edition) –
Helen Rimington and John Chambers (Nov 2015)
▪ Echocardiography (Oxford Specialist Handbooks in Cardiology (2nd edition) – Paul Leeson et
al. (2012)
▪ Making Sense of Echocardiography: A Hands-on Guide (2nd edition) –Andrew Houghton
(2013)

Protocols and the most up to date BSE guidelines are available under the Education tab of
www.bsecho.org.

Please note that only fully subscribed BSE members are granted full access to all education and
exam content.

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Appendix 4: Written examination registration guidance

BSE written exams are delivered in partnership with Pearson VUE. Candidates will be able to sit the exam at
local centres throughout the UK, the Republic of Ireland, and some overseas areas.

Pre-registration (through the BSE website)

▪ Candidates must register their interest to sit the written exam by completing an online pre-
registration form via the accreditation section of www.bsecho.org. The pre-registration window is
open for up to four weeks.
▪ Candidates registered names should appear the same as per their photo identification. Pearson Vue
follows a strict admission policy.
▪ BSE will transfer your data and requirements to Pearson VUE, who will contact all pre-registered
candidates with further information on confirming placements for the exam.

Delivery methods: Pearson VUE offers two ways of taking the exam.
1. Test Centre (recommended): Several Pearson VUE test centres are predominately in the UK, the
Republic of Ireland, and some overseas areas. Find your nearest test centre by visiting
https://home.pearsonvue.com/bse and click on ‘find nearest test centre’.
2. Online proctored exam known as OnVue: this method allows candidates to sit the exam at home
(subject to system requirements). Please note that if taking the exam from home, it is the candidates
responsibility to ensure that personal equipment and internet bandwidth is sufficient to run the
exam.

Special accommodations
▪ Pearson Vue can provide special accommodations to candidates who have official requirements,
such as extra time, or the need for medication during the examination.
▪ For further information on accommodations, please visit- https://home.pearsonvue.com/Test-
takers/Accommodations.aspx.
▪ All requests must be submitted with supporting documents to support claims for special
accommodations. Requests will be approved at the discretion of the BSE. Forward such requests
to [email protected].

Registration (through Pearson Vue)

▪ All registration and payments are managed by Pearson VUE after the stage of pre-registration.
▪ Pay by debit/credit card online when booking your exam placement.
▪ Candidates with special requirements or conditions should notify the BSE during the pre-registration
stage.
▪ Cancellations made in less than 7 days do not qualify for a refund. All cancellations must be
processed through Pearson Vue.

On the day of the exam

▪ Instructions will be given on the exam day via a video tutorial at the test centre or OnVUE online
proctored. Candidates will complete the exam on a computer at the test centre.
▪ A basic calculator (non-scientific) is already built into the online exam. An erasable sheet will be
given to candidates by the examining centre. If sitting the exam from home using online proctoring-
a calculator and whiteboard are built into the exam.
▪ Candidates are not required to bring any stationery to the exam.

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 ▪ Candidates are required to bring a photo ID. Please ensure that the registration details match your
photo ID exactly otherwise, you will be refused entry. If denied entry, candidates should contact BSE
immediately.
▪ The test centre will not facilitate any last-minute requests for special accommodations.

Results
▪ Results are released 4-6 weeks after sitting the exam. Scores will be uploaded to BSE personal profiles.
Both sections must be passed to achieve a complete pass grade.
▪ Pass: candidates will be issued with login details to the portal to begin uploading cases. The
submission deadline will appear at the 'Practical submission deadline' in the member profile.
▪ Fail: candidates can register interest to sit the next exam sitting.
▪ The reduced fee only applies to candidates who physically sat the exam and were unsuccessful; the
next attempt must be taken at the next sitting (within 12 months).

Please watch the demo available via Pearson VUE; http://www.pearsonvue.com/demo/

Additional Information

Candidates are advised to check the security procedures in the "What to expect section" of
the Pearson VUE/BSE guide page; https://home.pearsonvue.com/test-taker/security.aspx

Pearson Vue operates a strict admissions policy. Candidates registered names should be exactly as they
appear on their government photographic ID.

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Appendix 5: Examples of written exam multiple choice questions
Answer 'True' (T) or 'False' (F) to each of the following.
There is no negative marking - one mark added for a correct answer, no mark deducted for an incorrect
answer.

Q1 In an ultrasound imaging system:

a) Sector width, sector depth and frame rate can all be controlled independently F
b) Frame rate falls as sector width increases T
c) Using a lower frequency transducer improves the frame rate F
d) Frame rate increases as sector depth increases F
e) Using Colour Flow Doppler reduces the frame rate T

Q2 On a spectral Doppler display:

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

Q3 An atrial septal defect (ASD) may be associated with:

a) Paradoxical interventricular septal motion T
b) No obvious defect of the atrial septum on imaging T
c) Right ventricular dilatation T
d) Left ventricular dilatation F
e) Flow of blood from left atrium to right atrium T

Q4 Regarding assessing aortic stenosis:

a) Aortic valve maximum velocity of 5.2m/s is consistent with severe AS F
b) A mean gradient of 30mmHg and a valve ratio of 0.20 is consistent with severe AS F
c) In severe AS there is rapid acceleration and early peaking of the Doppler waveform F
d) A rate of change of >0.9m/s/year is associated with poor patient prognosis F
e) An aortic valve velocity ratio of 0.34 and a maximum velocity of 3.8m/s is consistent T
with moderate AS

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Appendix 6: Examples of the written exam image reporting questions
A number of moving clips and stills will be included in each question. Although these can be
viewed and replayed as many times as the candidate wishes, the candidate should be mindful
of the time spend on each question.

The SINGLE BEST ANSWER should be selected.

There is no negative marking - one mark added for a correct answer, no mark deducted
for an incorrect answer.

Case 1
Request: male, 42 year old, admitted with chest pain radiating into back, SOBOE.

Data: LVIDd: 7.4cm, SoV dimension: 7.0cm, STJ: 6.9cm, proximal ascending aorta: 7.4cm, TAPSE: 1.4cm.
proximal RVOT dimension: 4.2cm. Descending aorta end diastolic velocity: 0.30m/s. TR Vmax: 3.2m/s,
right atrial area: 26cmsq, pulmonary valve acceleration time: 100ms, AR Pressure half time: 149msec.

1.1 Regarding the severity of the aortic regurgitation Answer

a There is moderate central aortic regurgitation
b There is moderate eccentric aortic regurgitation
c There is severe central aortic regurgitation T
d There is severe eccentric aortic regurgitation

1.2 Regarding the echo probability of pulmonary hypertension

a There is no echo probability of pulmonary hypertension
b There is low echo probability of pulmonary hypertension
c There is intermediate echo probability of pulmonary hypertension
d There is high echo probability of pulmonary hypertension T

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Appendix 7: BSE logbook portal user guidance

1. User Login Details:

• Request login details by emailing the accreditation team- [email protected].

- Provide your BSE ID number, the type of *accreditation you are pursuing.
- Also, inform us of your mentor's name and email address- we will assign them to your
logbook.
• An automated message from the portal will be emailed to you with your login details.
• Link to the portal: https://logbook-v2.bsecho.org/login

a. If you have forgotten your password, please click the link titled

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2. Update your profile

• Click on your name, then 'Profile' to update your name, email and password.

Enter new password and click 'save.'

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3. User dashboard (e.g. Candidate, Mentor or Assessor)

• Click on the visible heading to access your dashboard

a. Enter Written Exam Date

• Click on to bring up the calendar and select the date you sat the written exam.

b. Click the box under the Logbook title to begin uploading PDF reports. The portal will take only PDF uploads.

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To add a new case, click on 'Add a new Case', give it a Title, enter the date of the case and Choose File.

• Explore the features and tools by hovering over the icons to find what they can do.
• To save your work, click , to delete click

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The 'Redact' tool allows masking over unwanted data. Click the Save button to keep the anonymise changes.

You can add logbook or case comments to share with your mentor only.

4. Competencies

Your mentor will access your portal via their login and sign off each of the competencies.

Candidate can view the progress in the dashboard.

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a. Mentor view:

The mentor clicks the sections below the 'DATE SIGNED OFF' header to sign off competencies by clicking on 'Sign
off.'

When mentor has completed competency sign off, they must do the same for the 'Mentor statement.'

5. Candidate logbook submission

Candidate can check the progress of their logbook in the dashboard and click the arrow after 'In Progress'.

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a. Verify and submit

Check you have completed the requirement before clicking 'Continue.'

b. Enter Head of Department Email Address and click submit:

c. Contact [email protected] to inform you have entered your HOD's email address and clicked
submit.

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6. Validate logbook

Your Head of Department must click the link to accept the statement.

a. Head of Department verified

After clicking the statement, the Head of Department receives the message below.

Please note that some NHS emails may block messages from the logbook portal- [email protected]. In
this case, candidates should consider providing an alternative email address, e.g. non-NHS email addresses.

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7. Logbook submitted

Once the logbook has been validated, it is ready for an assessor to mark.

• No further action is required from this point.

• Candidates will be notified when marking is complete.

Updated: JV- 14/04/2022

End of guide.

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Appendix 8: Logbook guidance and marking criteria
In order to meet all competencies of this accreditation process the logbook should represent good/excellent
examples of a candidate's daily workload. Ideally, it should reflect the most up to date BSE guidance (see page
7 if your department has different locally agreed working practices).

Whilst we encourage the use of good/excellent work to be included in the logbook, it is acknowledged that
not every report in the logbook will meet this standard. Therefore, when considering whether to include a
report, please refer to the following as an absolute minimum.

***If a report does not meet the below, it should not be included as a logbook report***

Clinical question: Must be stated.

Patient Ht, Wt and BSA: should be given unless it is not possible to obtain these measurement (reasons for this
should be stated e.g. patient in bed)
BP: Should be included particularly where clinically relevant (i.e. aortic stenosis, LVH).

Left ventricle:
Descriptive section:
• Comment on left ventricular cavity size, absence/presence (and degree) of hypertrophy
• Comment on global left systolic function, including regional wall motion abnormalities if present
• Comment on left ventricular diastolic function
Measurements / analysis section:
• LV diastolic and systolic dimensions, LV wall thicknesses
• Visually estimated ejection fraction
• E wave velocity, A wave velocity, E wave deceleration time, e' velocities, E/e' (can be reported under
mitral valve section), mitral annular S'

Mitral valve:
Descriptive section:
• Comment on mitral valve structure, leaflet thickness and mobility
• Comment on absence/presence of mitral stenosis
• Comment on absence/presence of mitral regurgitation
Measurements / analysis section:
• E wave velocity, A wave velocity, E wave deceleration time (can be reported under LV section)
If stenosis is present:
• A range of measurements taken from BSE guidelines.
If more than mild regurgitation is present:
• A range of measurements taken from BSE guidelines.

Left atrium:
Descriptive section:
• Visually comment on left atrial size
Measurements/analysis section:
• If seen, monoplane volume (A4C or A2C)

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Aortic valve:
Descriptive section:
• Comment on aortic valve structure, leaflet thickness and mobility
• Comment on absence/presence of aortic stenosis
• Comment on absence/presence of aortic regurgitation
Measurements/analysis section:
• Aortic Vmax, maximum and mean gradient, aortic VTI.
• Left ventricular outflow tract Vmax, left ventricular outflow tract max and gradient, left ventricular
outflow tract VTI
If stenosis is present:
• Measurements as above plus: aortic valve area or dimensionless index
If more than mild regurgitation is present:
• A range of measurements taken from BSE guidelines

Aorta:
Descriptive section:
• Comment on aortic root, proximal ascending aorta and aortic arch size or, "not well seen to assess" if
more appropriate
Measurements/analysis section:
• If seen; sinuses of valsalva dimension, sino-tubular junction dimension, proximal ascending aorta
dimension

Right ventricle:
Descriptive section:
• Comment on right ventricular size
• Comment on global right ventricular systolic function.
Measurements/analysis section:
• RVD1
• TAPSE

Right atrium:
Descriptive section:
• Visually comment on right atrial size
Measurements/analysis section:
• If seen, RA area

Tricuspid valve:
Descriptive section:
• Comment on tricuspid valve structure, leaflet thickness and mobility or, "not well seen" if more
appropriate
• Comment on absence/presence of tricuspid stenosis
• Comment on absence/presence of tricuspid regurgitation
Measurements / analysis section: Tricuspid regurgitation Vmax (if tricuspid regurgitation present) or "no
measurable tricuspid regurgitation Vmax" if more appropriate
If stenosis is present - A range of measurements taken from BSE guidelines
If more than mild regurgitation is present - A range of measurements as per BSE guidelines

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Pulmonary valve:
Descriptive section:
• Comment on pulmonary valve leaflet thickness and mobility or, "not well seen" if more appropriate.
Measurements/analysis section: If seen, pulmonary valve Vmax
If stenosis is present - A range of measurements taken from BSE guidelines
If more than mild regurgitation is present - A range of measurements taken from BSE guidelines

Pulmonary hypertension:
Descriptive section:
• Comment on echocardiography probability of pulmonary hypertension or "unable to comment" if
more appropriate
Measurements/analysis section:
• Tricuspid regurgitation Vmax (if present), at least one further echocardiography parameter to help
quantify the descriptive statement

Inferior Vena Cava:

Descriptive section:
• Comment size and collapsibility or, "not well seen" if more appropriate
Measurements/analysis section:
• If seen, IVC max dimension

Pericardium:
Descriptive section:
• Comment on absence/presence of pericardial fluid. If present: A comment location, size and
hemodynamic effects
Measurements / analysis section:
• If no pericardial fluid – N/A
• If pericardial effusion present: Effusion dimensions and assessment of haemodynamic effects which
may include: MV, TV, LVOT inflow variation with respiration, presence or absence of cardiac chamber
collapse, IVC size and collapsibility assessment

If a valve replacement is present:

Descriptive section:
• Replacement valve location, type and size (if known, or stipulate not known if more appropriate) and
stability of replacement valve
• Comment on absence/presence of prosthetic stenosis
• Comment on absence/presence of prosthetic regurgitation. Including likely origin of the regurgitant
jet
• Comparison to previous study where possible
Measurements/analysis section:
• A range of hemodynamic parameters assessing forward flow that is relevant to the replacement valve
position
• A range of parameters to assess regurgitation severity as per valve native disease

If a valve repair is present:

Descriptive section:
• Location and type of valve repair (if known, or stipulate not known if more appropriate) and stability

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 of repaired valve.
• Comment on absence/presence of repaired valve stenosis.
• Comment on absence/presence of repaired regurgitation. Including likely origin of the regurgitant jet

Measurements/analysis section:
• A range of hemodynamic parameters assessing forward flow that is relevant to the position of the
repaired valve
• A range of parameters to assess regurgitation severity as per valve native disease

Conclusion:
• Must summarise main findings
• A comparison to previous studies should made where possible

Logbook marking criteria:

When marking a candidate's logbook, the assessor will review a selection of reports in the candidate's logbook.

The following marking criteria is used when assessing each logbook report.

Does the report meet the following criteria? Yes / No (if no, state reasons why)
Fully anonymised
Indication for echo present
Appropriate measurements present
Appropriate Doppler calculations present
Do measurements/Doppler calculations match descriptions
All parts of heart described
Descriptions complete
Appropriate to request
Conclusion present

Logbook outcomes include:

Satisfactory logbook for BSE accreditation OR Unsatisfactory at present and a resubmission is required

If a logbook is unsatisfactory, the candidate will be asked for one of the following resubmissions

• 10-20 further specified reports: To address persistent inaccuracies in certain measurements or

observations (e.g. lack of diastolic function assessment).

• 25-75 further specified reports: To address repeated inaccuracies, lack of correct conclusion or lack
of sequential systematic comments on all parts of the heart. (e.g. lack of RWMA description and lack
of quantitative valve pathology measurements).

• 250 reports: To address significant errors, inaccurate or lack of systematic comments. The presence
of Patient ID on any report will require a complete resubmission of the logbook.

To ensure consistency across logbook marking, all logbooks are discussed with the national logbook leads
and chief assessor prior to a resubmission being requested.

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Appendix 9: Guidance for the removal of patient identifiable data
The duty of confidentiality arises out of the common law of confidentiality, professional obligations and
also staff employment contracts. Breach of confidence may lead to disciplinary measures, bring into
question professional reputation and possibly result in legal proceedings.

Guidance is provided to Healthcare Professionals in the 'NHS Code of Practice on Confidentiality'

(November 2003):
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/
dh_4069254.pdf

Patient information that can identify individual patients is confidential and must not be used or disclosed in
any part of the submission required for this accreditation process. In contrast, anonymised information is
not confidential and may be used.
Key identifiable information includes:

▪ Patient's name
▪ Address
▪ Full post code
▪ Date of birth
▪ NHS number and local identifiable codes

Key identifiable information may also include information that may be used to identify a patient directly or
indirectly. For example, rare diseases, drug treatment or statistical analyses which have very small numbers
within a small population may allow individuals to be identified.

Guidance to candidates submitting logbooks and cases for accreditation

The NHS Code of Practice on confidentiality means that evidence submitted for this accreditation process
must have removed ALL patient identifiable information beyond that of gender and age/year of birth.

Logbook reports – Please use the BSE online portal and electronically delete all patient information except
age and gender.

We would advocate against the use of other electronical anonymisation as sometimes data is still present.
If in doubt, manually remove patient identification information prior to use.

Video cases - We appreciate that the removal of patient ID may be difficult. Therefore advise that the video
cases are specifically collected, and the data inputs are made relevant to your cases (E.g. Patient Name
could be 'BSE Case 1', Patient Number could be your membership number followed by case number, '1111-
1').

The final decision remains at the discretion of the Chair of Accreditation.

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Appendix 10: Practical scanning mark scheme
The marking criteria used for the practical scanning assessment can be seen below.

• Familiarisation of echo machine / equipment.

2 minutes: • Assessor will be on hand if assistance is required.
• Candidate to have 2 minutes to obtain and acquire each image.
20 minutes: • The assessor will instruct the candidate on the images to acquire.
• The assessor can alter echo machine / equipment setting to optimise images at the
direction of the candidate.

The pass mark is set at 83 points. Once this mark is achieved the candidate will be deemed as being
successful at this station.

Each image the candidate acquires is scored as per the marking scheme below.

All images used in the practical scanning assessment are taken from the BSE minimum dataset. An example of
the imaging list used in this assessment can be seen below.

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 Appendix 11: Patient case studies viva marking criteria
The next few pages show the individual marking criteria for each of the patient video case studies.

All criteria must be met to a satisfactory standard in order for the patient case study to be passed.

A minimum of two patient case studies will be assessed. The British Society of Echocardiography reserves the
right to assess all five patient viva cases.

Adult Transthoracic Accreditation. Case 1 – No significant pathology.

Practice must be satisfactory in all areas to pass
Evidence of satisfactory practice Tick Evidence of unsatisfactory practice Tick
ECG ECG
Largely present throughout without 2D Unstable or frequently absent, making
image interference timings inaccurate
Optimisation Optimisation
Infrequent, non-repetitive optimisation Frequent, repetitive optimisation
errors which do not detract from the case conclusion errors which detract from the case conclusion

Complete study Incomplete study

Images are complete enough to allow full assessment of Images are missing which are relevant to the
the selected pathology, including Doppler study and accurate assessment of the selected pathology,
measurements including inadequate Doppler study or relevant
measurements quoted in report but not
demonstrated.
2D measurements 2D measurements
Accurate throughout with minor errors that do not change Frequent inaccuracies or isolated inaccuracies
the categorisation of the chosen pathology that change the categorisation of the chosen
pathology
Colour Doppler Colour Doppler
Accurate box size, gain, scale and baseline settings Frequent inaccuracies of box size, gain, scale and
demonstrating anatomy clearly baseline settings which
prevent clear demonstration of the anatomy

Spectral Doppler Spectral Doppler

Accurate use with good cursor alignment and Inaccurate use with poor cursor alignment or
optimised waveforms waveform optimisation
altering pathology assessment

Pathology assessment Pathology assessment

No images missing which are key to pathology Poor quality or missing images missing which are key
assessment to pathology assessment

No measurements significantly inaccurate that are key Measurements key to pathology assessment
to pathology assessment significantly inaccurate and change the categorisation
of the pathology

Report is complete and accurate Report is incomplete or inaccurate

Comprehensive/accurate description of all parts of the Partial/inaccurate description of parts of the heart
heart
Correct categorisation of chosen pathology (NB none Incorrect categorisation of chosen pathology
significant abnormalities may be included in this case) Incorrect interpretation of findings in the clinical
Correct interpretation of findings in the clinical context
context

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Adult Transthoracic Accreditation. Case 2 – Aortic Stenosis.
Practice must be satisfactory in all areas to pass
Evidence of satisfactory practice Tick Evidence of unsatisfactory practice Tick

ECG ECG
Largely present throughout without 2D image Unstable or frequently absent making
interference timings inaccurate
Optimisation Optimisation
Infrequent, non-repetitive optimisation errors which do Frequent, repetitive optimisation errors which
not detract from the case conclusion detract from the case conclusion
Complete study Incomplete study
Images are complete enough to allow full Images are missing which are relevant to the
assessment of the selected pathology, including accurate assessment of the selected pathology,
Doppler study and measurements including inadequate Doppler study or relevant
measurements quoted in report but not
demonstrated

2D measurements 2D measurements
Accurate throughout with minor errors that do not Frequent inaccuracies or isolated
change the categorisation of the chosen pathology inaccuracies that change the
categorisation of the chosen pathology
Colour Doppler Colour Doppler
Accurate box size, gain, scale and baseline settings Frequent inaccuracies of box size, gain, scale and
demonstrating anatomy clearly baseline settings which
prevent clear demonstration of the anatomy

Spectral Doppler Spectral Doppler

Accurate use with good cursor alignment and Inaccurate use with poor cursor alignment or
optimised waveforms waveform optimisation
altering pathology assessment
Pathology assessment Pathology assessment
Good quality CW from the A5C and stand-alone CW Missing, poor quality or significantly lower
from at least one other window. stand-alone CW signal.

No images missing which are key to pathology Images missing which are key to
assessment pathology assessment

No measurements significantly inaccurate that are Measurements key to pathology

key to pathology assessment (LVOT assessment significantly inaccurate and change
diameter, LVOT VTi and aortic VTi) the categorisation of the pathology (LVOT
diameter, LVOT VTi and aortic VTi)
Report is complete and accurate Report is incomplete or inaccurate Partial and
Comprehensive and accurate description of all parts inaccurate description of parts of the heart
of the heart
Incorrect categorisation of chosen
Correct categorisation of chosen pathology (NB pathology
trivial abnormalities may be included in this case)
Incorrect interpretation of findings in the
Correct interpretation of findings in the clinical clinical context
context

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Adult Transthoracic Accreditation. Case 3 – Regurgitation.
Practice must be satisfactory in all areas to pass
Evidence of satisfactory practice Tick Evidence of unsatisfactory practice Tick
ECG ECG
Largely present throughout without 2D Unstable or frequently absent making
image interference timings inaccurate
Optimisation Optimisation
Infrequent, non-repetitive optimisation errors Frequent, repetitive optimisation errors which
which do not detract from the case detract from the case conclusion
conclusion
Complete study Incomplete study
Images are complete enough to allow full Images are missing which are relevant to the
assessment of the selected pathology, including accurate assessment of the selected pathology,
Doppler study and measurements including inadequate Doppler study or relevant
measurements quoted in report but not
demonstrated
2D measurements 2D measurements
Accurate throughout with minor errors that do Frequent inaccuracies or isolated
not change the categorisation of the chosen inaccuracies that change the
pathology categorisation of the chosen pathology
Colour Doppler Colour Doppler
Accurate box size, gain, scale and baseline Frequent inaccuracies of box size, gain, scale and
settings demonstrating anatomy clearly baseline settings which
prevent clear demonstration of the anatomy

Spectral Doppler Spectral Doppler

Accurate use with good cursor alignment and Inaccurate use with poor cursor
optimised waveforms alignment or waveform optimisation altering
pathology assessment
Pathology assessment Pathology assessment
Good assessment of regurgitation. Poor or inadequate assessment of severity.
Understanding of the methods available to Failure to return Doppler baseline to normal
assess severity and accurate demonstration if after PISA assessment
appropriate (eg PISA/Vena
contracta/RV/ERO/PV flow) Images missing which are key to pathology
assessment
No images missing which are key to
pathology assessment Measurements key to pathology
assessment significantly inaccurate and
No measurements significantly inaccurate that change the categorisation of the pathology
are key to pathology assessment
Report is complete and accurate Comprehensive Report is incomplete or inaccurate Partial and
and accurate description of all parts of the heart inaccurate description of parts of the heart
Correct categorisation of chosen Incorrect categorisation of chosen pathology
pathology Incorrect interpretation of findings in the clinical
Correct interpretation of findings in the clinical context
context

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Adult Transthoracic Accreditation. Case 4 – RWMA
Practice must be satisfactory in all areas to pass
Evidence of satisfactory practice Tick Evidence of unsatisfactory practice Tick
ECG ECG
Largely present throughout without 2D Unstable or frequently absent making
image interference timings inaccurate
Optimisation Optimisation
Infrequent, non-repetitive optimisation errors Frequent, repetitive optimisation errors which
which do not detract from the case detract from the case
conclusion conclusion
Complete study Incomplete study
Images are complete enough to allow full Images are missing which are relevant to the
assessment of the selected pathology, including accurate assessment of the selected pathology,
Doppler study and measurements including inadequate Doppler study or relevant
measurements quoted in report but not
demonstrated
2D measurements 2D measurements
Accurate throughout with minor errors that do Frequent inaccuracies or isolated
not change the categorisation of the chosen inaccuracies that change the
pathology categorisation of the chosen pathology
Colour Doppler Colour Doppler
Accurate box size, gain, scale and baseline settings Frequent inaccuracies of box size, gain, scale
demonstrating anatomy clearly and baseline settings
which prevent clear demonstration of the anatomy
Spectral Doppler Spectral Doppler
Accurate use with good cursor alignment and Inaccurate use with poor cursor
optimised waveforms alignment or waveform optimisation altering
pathology assessment

Pathology assessment Pathology assessment

Appropriate measurement of Simpson's biplane Incomplete assessment of Simpson's or
showing systolic and diastolic measurements in measured inaccurately which leads to a change
both A4C and A2C which correlates with visual the categorisation of the reported LVEF
impression
Images missing which are key to pathology
No images missing which are key to assessment
pathology assessment
Measurements key to pathology assessment
No measurements significantly inaccurate that are significantly inaccurate that change the
key to pathology assessment categorisation of the pathology
Report is complete and accurate Report is incomplete or inaccurate
Comprehensive and accurate description of all Partial and inaccurate description of parts of
parts of the heart including RWMAs the heart including RWMAs

Correct categorisation of chosen pathology Incorrect categorisation of chosen pathology

Correct interpretation of findings in the clinical Incorrect interpretation of findings in the clinical
context context

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Adult Transthoracic Accreditation. Case 5 – Other pathology.
Practice must be satisfactory in all areas to pass
Evidence of satisfactory practice Tick Evidence of unsatisfactory practice Tick
ECG ECG
Largely present throughout without 2D Unstable or frequently absent making
image interference timings inaccurate
Optimisation Optimisation
Infrequent, non-repetitive optimisation errors Frequent, repetitive optimisation errors which
which do not detract from the case detract from the case
conclusion conclusion
Complete study Incomplete study
Images are complete enough to allow full Images are missing which are relevant to the
assessment of the selected pathology, including accurate assessment of the selected pathology,
Doppler study and measurements including inadequate Doppler study or relevant
measurements quoted in report but not
demonstrated.
2D measurements 2D measurements
Accurate throughout with minor errors that do Frequent inaccuracies or isolated
not change the categorisation of the chosen inaccuracies that change the
pathology categorisation of the chosen pathology

Colour Doppler Colour Doppler

Accurate box size, gain, scale and baseline settings Frequent inaccuracies of box size, gain, scale
demonstrating anatomy clearly and baseline settings which prevent clear
demonstration of the anatomy

Spectral Doppler Spectral Doppler

Accurate use with good cursor alignment and Inaccurate use with poor cursor
optimised waveforms alignment or waveform optimisation altering
pathology assessment
Pathology assessment Pathology assessment
No images missing which are key to Images missing which are key to pathology
pathology assessment assessment

No measurements significantly inaccurate that are Measurements key to pathology assessment

key to pathology assessment significantly inaccurate and change the
categorisation of the pathology
Report is complete and accurate Report is incomplete or inaccurate
Comprehensive and accurate description of all Partial and inaccurate description of parts of
parts of the heart the heart

Correct categorisation of chosen Incorrect categorisation of chosen pathology

pathology
Incorrect interpretation of findings in the clinical
Correct interpretation of findings in the clinical context
context

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