Guidelinesfor Optimal in Echocardi Recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography ALAN S. PEARLMAN, MD, Chairman, JULIUS M. GARDIN, M RANDOLPH P. MARTIN, MD, ALFRED F. PARISI, MD, RICHARD L. POPP, MIGUEL A. QUINONES, MD, and d. GEOFFREY STEVENSON, MD Over the past few years, the clinical use of echocardiography has continued to expand. Echocardiographic techniques are used widely to define normal and abnormal cardiac anatomy, evaluate cardiac chamber sizes and dynamics, assess valvular and pericardial diseases, detect intracavitary masses, measure pressure gradients across discrete stenoses, determine flow volumes, detect and assess the severity of valvular regurgitation, demonstrate and quantitate intracardiac shunts, and measure the timing of cardiac events. These and related applications have led to the increasing use of echocardiography in the diagnostic evaluation of many cardiac disorders. Echocardiography requires considerable theoretical knowledge, technical skill and practical experience to be used in an optimal manner. Previous publications have suggested guidelines for physician training in the techniques of M-mode and 2-dimensional echocardiography. The clinical applications of echocardiography continue to grow, however, and Doppler techniques for evaluating blood flow have become an established component of the echocardiographic evaluation of many disorders. This article presents the current recommendations of the American Society of Echocardiography as to the background knowledge, the nature and amount of practical experience, and the type of training site that are optimal for the training of physicians who take responsibility for the conduct and interpretation of echocardiographic studies. (Am J Cardiol 1987;80:158-163) s ocieties that represent professionals who practice certain cardiovascular diagnostic techniques have from time to time set forth what they consider to be optimal standards for the performance and utilization of these techniques. l-lo In the case of noninvasive evaluation of cardiac structure and function using ultrasonic techniques, the American Society of Echocardiography has provided direction. This Society, representing more than 3,000 physicians and sonographers who practice echocardiography, has published recommended measurement standards for M-mode echonomenclature and display standards cardiography,ll for 2-dimensional echocardiographic images,12 and techniques and applications for contrast echocardiography.13 In addition, this Society has prepared documerits* that establish standards for physician training in M-mode and 2-dimensional echocardiography, education and training of the sonographer,15 identification of myocardial wall segments,l” terminology and display conventions for Doppler echocardiography,17 and nomenclature for cardiac septa.18 Continuing evolution of 2-dimensional echocardiographic techniques and applications, coupled with the explosive growth of Doppler echocardiography over the past several years, has stimulated the American Address for reprints: Alan S. Pearlman, Cardiology, RG-22, University of Washington, ton 98195. *These documents are available by request from the American Society of Echocardiography, P.Q. Box 2598, Raleigh, North Carolina 27602. MD, Division of Seattle, Washing158 July 1, 1987 Society of Echocardiographyto instruct the Committee for Physician Training in Echocardiography to develop updated guidelines for optimal physician training in the field of echocardiography.The guidelines that follow represent the current recommendations of the American Societyof Echocardiographyfor the training of physicianswho are responsiblefor the performance and interpretation of echocardiographic examinations. GeneralOverview The comprehensiveechocardiographicevaluation of the patient with known or suspectedheart disease may involve the useof severalrelated diagnosticultrasonic techniques:M-mode, Z-dimensional and Doppler echocardiography.In a given patient, any or all of thesemodalities may be usedto assessthe nature and severity of a suspectedcardiacdisorder.In somecases, contrast echocardiographictechniques, stress echocardiography or invasive echocardiographicstudies may also be appropriate. We consider these to be a family of diagnostictechniques,and will refer to them under the general term “echocardiography.”Each of thesetechniqueshasits set of specific underlying principles, instrumentation, applications, advantagesand shortcomings.Nonetheless,we emphasizethat these are related and usually complementary techniques; they are not competing diagnostic procedures to be used independently. For this reason,physicians who take responsibility for the performance and interpretation of echocardiographic studies should have a clear understanding of the fundamental principles of M-mode, &dimensional and Doppler echocardiography, and practical experience with all of these techniques. This documentset forth our recommendationsasto what constitutes optimal physician training in echocardiography, rather than establishing requirements for training in cardiac noninvasive diagnostictesting. We recommend relatively extensive exposureto the theoreticalprinciples and the practical applicationsof the various echocardiographictechniques.We believe that, althoughit may not always be easyto accomplish, adherenceto theseguidelines will increasethe likelihood that echocardiographicstudies will yield accurate and clinically meaningful data,thereby leading to improved patient care. Echocardiographicstudies are relatively inexpensive compared with other forms of cardiac diagnostic testing, and the necessaryinstrumentation is readily available from a number of manufacturers. Because thesestudiesare noninvasive and apparentlynoninjurious, and becausethey provide valuable diagnostic information in a wide variety of cardiac disorders, many physicians [cardiologists and noncardiologists] may be tempted to consider providing echocardiographic services.Although it is neither our intent nor our desire to restrict the performance and use of highquality echocardiographicstudies, it is our firm conviction that substantial training is needed to provide optimal echocardiographicservices.In other words, it is much more difficult to acquire the necessaryskills than to purchasethe needed equipment. Echocardio- THE AMERICAN JOURNAL OF CARDIOLOGY Volume 60 150 graphic examinationsarenot automatedor technically routine; transducer positioning, instrument controls and examination technique all must be adaptedto the patient being studied and the problems being evaluated.The physician responsiblefor the conductand content of echocardiographicstudiesmust be thoroughly familiar with thesetechnical details in order to evaluate the quality of the data and arrive at the proper diagnosticconclusions.The responsiblephysician also must be familiar with normal and abnormal cardiac structure,dynamics and blood flow. Finally, the proper use of echocardiographicfindings for clinical decision-making requires not only significant expertisein echocardiography,but also substantialunderstanding of cardiovasculardiseasein general.Thus, physicians responsible for echocardiographic studies need to have considerable skills, and these skills are not acquired quickly. Physicianswho supervise echocardiographicstudies and interpret the significance of the findings must be not only capable of interpreting the findings, but also trained and adequatelyskilled in performing the examination, One must know how to acquire echocardiographic recordingsin order to judge the technical quality and reliability of the data. Moreover, the recording of echocardiographic images and Doppler flow waveforms provides an ideal means to learn the tomographicanatomy of the heart, permits the operator to define the spatial relation betweendifferent cardiac structuresand assistsin the understandingof flow dynamics. In addition, performance of the study is an invaluable aid to recognizingthe audible Doppler frequenciesthat characterizecardiovascularblood flow. Although most clinical echocardiographicstudies in the U.S. now areactually performed by trained technical personnel, often the responsible physician may need to perform part or all of the examination in order to clarify incomplete or confusing findings. He or she must alsobe knowledgeablein examinationtechnique in order to provide appropriate supervision to others who perform echocardiographicstudies.The person performing thesestudiesmust have not only considerable technical ability but alsothe experienceandjudgment to evaluatethe findings accurately,immediately and continuously during data acquisition. Otherwise, adequatedata may not be recorded and the results of the study may be inconclusive, misleading or erroneous.For all of thesereasons,the supervisingphysician must be skilled in examination techniques as well as diagnosticinterpretation in order to ensurestudies of optimal technical (and thus diagnostic] quality. The echocardiographicexamination should answer thosequestionsposedby the referring physician,but it should alsoattemptto detectand quantitateabnormalities that may be clinically inapparent or unsuspected. In this way, individual patients will receive the greatest benefit from thesestudies. Recommended BackgroundKnowledge Physicians who take responsibility for the performance and interpretation of echocardiographicstudies should have: (11 a detailed understanding of the physical principles of image formation and blood flow 160 PHYSICIAN TRkiNING ‘N ECHOC,4FXDEOGRAPhY velocity measurement using ultrasound; (4 substantial familiarity with echocardiographic instrumentation and an understanding of how to use it properly and safely; (3) a thorough knowledge of cardiac anatomy, physiology, hemodynamics and pathology; (4) a detailed understanding of the fluid dynamics of normal and abnormal cardiovascular blood flow; [5) substantial familiarity with the echocardiographic techniques used to evaluate cardiovascular anatomy, dynamics and blood flow in the clinical setting; (6) the experience needed to recognize and interpret both normal and abnormal images and blood flow patterns and the ability to relate these findings to anatomic, physiologic, hemodynamic and pathologic findings: (7) experience with cardiac auscultation, electrocardiography, chest radiography, cardiac catheterization and angiography, and other cardiac diagnostic techniques, in order to relate echocardiographic findings to the results of these examination methods, when available; (61 an understanding of the clinical problems of each patient and the presumed differential diagnoses; and (9) the ability to use echocardiographic techniques to investigate these differential diagnoses. These guidelines also set forth our recommendations for the nature and amount of practical training that we believe appropriate for those physicians who will be responsible for echocardiographic studies. It is ideal when this experience can be gained during a period of formal training in a well-established cardiac noninvasive laboratory. Such a training program will enable the physician-trainee to acquire, in a supervised setting, a working knowledge of the physical principles and the various techniques of echocardiography, and it will allow him or her to become sufficiently skilled and experience to perform and interpret echocardiographic studies independently. The physician-trainee must become familiar with normal and abnormal images of cardiac structure and dynamics, and must learn to recognize the audible patterns of normal and pathologic blood flow. Optimally, the training program will allow the physician-trainee to develop experience in evaluating the wide variety of diagnostic challenges seen in an active, hospital-based echocardiographic practice. Recommended Practical Experience Physicians training in echocardiography ideally should spend a specified period of time in an active echocardiographic laboratory, working under the direction of an established and experienced physicianechocardiographer who has achieved at least level 3 competence [Table I). The rate at which a given physician-trainee becomes skilled in performing and interpreting echocardiographic studies will depend on his or her previous training, knowledge and technical abilities, the number and type of patients examined, and the teaching abilities of the laboratory personnel and the physician-supervisor. We recommend that each trainee keep a log of those studies that he or she has performed or interpreted during training, including the procedures performed and the diagnoses made. ractical experience re cians in cardiology training The recent Bethesda Conference on Adult Cardiology TrainingI recommended 3 levels of training in echocardiography for cardiology fellows, leading to 3 corresponding levels of expertise. The first, or basic, level of training would be an introductory experience designed to familiarize every cardiology fellow with the techniques, applications and shortcomings of echocardiography; its completion would not qualify the trainee to perform or interpret echocardiograms independently. The second, or intermediate, level of training would provide sufficient additional experience to qualify the trainee to take independent responsibility for the performance and interpretation of echocardiographic studies. The third, or advanced, level of training would provide enough expertise to qualify the trainee to direct an echocardiographic laboratory in an academic or community hospital, or a group practice setting. We endorse these three tiers of training [Table I] as appropriate. All cardiology trainees should spend approximately 3 months undergoing a period of introductory training in echocardiography. This period of training should be devoted primarily to echocardiography; the trainee should not be expected to spend more than 20% of his or her time in other clinical activities. During this introductory period of training, each fellow optimally should perform and interpret at least 150 echocardiographic imaging studies, using both &dimensional and M-mode techniques. The fellow should also perform and interpret at least 75 Doppler examinations during this same period of training. Although we recommend a smaller number of Doppler examinations than echocardiographic imaging studies, this should not be interpreted to mean that Doppler studies are relatively unimportant. We believe that a basic understanding of tomographic cardiac anatomy and dynamics provides a helpful framework for learning and understanding Doppler evaluation of blood flow dynamics, and we recognize that in many laboratories, Doppler studies are not performed in all patients (although the percentage in whom these studies are done is increasing). All echocardiographic studies should be performed “in a noninvasive echocardiographic laboratory which is under the direction of an established physician echocardiographer who oversees the performance and interpretation of all studies.“14 Such a period of intensive study should allow the physician-trainee to develop an appreciation of the principles of echocardiographic imaging and instrumentation, the techniques of patient examination, the tomographic anatomy of the heart and great vessels, and cardiac dynamics as visualized by both 2-dimensional and M-mode echocardiography. The trainee also would become familiar with Doppler principles and instrumentation, examination techniques, and both audible and graphic outputs of Doppler data. This experience will give the physician-trainee better insight into how echocardiography can be used to assess cardiac anatomy and function and lead to a better understanding of the clinical indications for echocar- July 1, 1987 TABLE I Duration Physicians 1 Level 2 Introductory Sufficient in Cardiology experience experience to take independent responsibility for echocardiographic Level 3 JOURNAL OF CARDIOLOGY Volume 60 161 Levels of Training in Echocardiography Objectives Level THE AMERICAN Sufficient No. of Cases Training Program 3 months 160 2-D/M-mode examinations 75 Doppler examinations 3 additional 150 P-D/M-mode months (beyond level 1) 150 Doppler 6 additional 450 examinations months (beyond level 2) both imaging examinations examinations studies expertise to direct an echocardiography laboratory Physicians Responsibility Post-Cardiology for per- formance and interpretation of echocardiograms (using and Doppler) Training variable; 250-300 level of achievement mode and Doppler equivalent patients (2-D/Mexamina- tions) to level 2 above Direct echo laboratory hospital or large group in practice variable; level of expertise 450 patients and Doppler (2-D/M-mode examinations) equiv- alent to level 3 above 2-D = 2dimensional. diographic evaluation. It should also help the physician-trainee to better appreciate the difference between adequate and inadequate echo/Doppler data. For the cardiology trainee to be considered sufficiently experienced to take full responsibility for independent interpretation and reporting of the findings and significance of echocardiographic studies, additional supervised experience in performing and interpreting at least 150 echocardiographic imaging studies and 150 Doppler blood flow evaluations, over a period of approximately 3 months, is recommended. During this second period of practical experience, the trainee should not be assigned other major responsibilities. This additional practical training period is intended to provide the physician-trainee a substantial body of experience in assessing abnormalities of cardiac structure and dynamics, measuring cardiac chamber and wall dimensions, quantitating ventricular function, determining flow velocities, calculating pressure gradients, computing flow volumes, determining the severity of regurgitant lesions, detecting and measuring shunts, and defining the timing of events during the cardiac cycle. Ideally, this period of training should provide exposure to a broad range of patients and clinical problems, with particular emphasis on the kinds of patients and disorders most likely encountered in the physician-trainee’s actual practice. At the end of this second period of training, the cardiology fellow should have achieved a level of experience and competence sufficient to allow him or her to function independently in an established echocardiography laboratory. For cardiology fellows who plan to direct an echocardiography laboratory, we recommend an additional 6-month period of training. During this period, which again should be devoted primarily to echocardiography, the cardiology trainee should perform or interpret an additional 450 echocardiographic studies, including both echocardiographic imaging and Doppler techniques. This additional training, which should involve patients with a wide variety of acquired and congenital cardiac disorders, would provide the trainee with sufficient experience so that he or she could take full responsibility for supervision and training of cardiac sonographers, performance of echocardiographic studies when appropriate, interpretation of echocardiographic studies, supervision of physicians training in echocardiography, and the integration of echocardiography into the overall activities of the cardiology program at his or her institution. For a cardiology trainee to attain this level of expertise, a total of 1.3 months of intensive training, involving echo/ Doppler studies in a total of at least 750 patients, is recommended. Practical experience recommended for physicians after cardiology training (i.e., in practice): This situation creates a dilemma. We realize that a period of intensive study such as that described may not be easily accomplished for many physicians who already have completed their formal training in cardiology, given the constraints of their clinical practices. On the other hand, we also recognize the technically demanding nature of ultrasonic imaging and Doppler exami- nations, know that performing a.ndinterpreting these studiesboth requi:resubstantial.s!kili, and believe that a significant mnm~~n.~: of guidancefrom an experienced physician-echocardiographeris highy desirable. In this regard, it may be useful to consider the training needed to perform an.d interpret electrophysiologic studies or the expertise needed to select appropriate candidates for percutaneous ,transluminal coronary angioplasty and to perform th.e dilation procedures. Physicians who have had no formal training in these tecniques certainly can retrain and thereby become competent in one or another of these areas,but not without significant effort. We believe that echocardiographyis similar in complexity, and these considerations lead us to suggestthat achievementof a level of expertiseequivalent to that recommendedfor cardiologyfellows (Table I) is also desirable for the physician in practice who wants to perform or interpret, or both, echocardiographicstudiesindependently. This is particularly true for physicians who will be responsible for hospital-basedechocardiographiclaboratories,becausethey are likely to be called on to evaluate critically ill patients in whom diagnosticinformation must be obtained efficiently and accurately. It is difficult to specify the length of training needed for the physician in practice to achievea level of competenceequivalent to that of a cardiology fellow who hashad 6 months (or more) of formal training in echocardiography, because practicing cardiologists come from a variety of backgrounds.In general, physicians who have finished fellowship optimally should perform and interpret echocardiographicstudies in at least 250 to 300 patients before they consider themselvessufficient in expertiseto make independent diagnosticjudgments and to use these results to determine patient management. Some of these studies could be performed in the trainee’s own institution, but it would be optimal if most of thesepatient studies were performed and interpreted under the supervision of an experienced physician-echocardiographer, and these studies should include both imaging and Doppler echocardiographictechniques. Many physicians who have finished cardiology fellowship training already have had experiencewith M-mode and 2dimensional echocardiography;their familiarity with echocardiographic anatomy and cardiac dynamics, their knowledge of hemodynamics,and their ability to correlate echocardiographicfindings with other clinical and laboratory data will certainly help them to learn Doppler echocardiography.We encouragepracticing cardiologistswho wish to useechocardiographic techniques in an optimal manner to obtain intensive instruction in both performing and interpreting echocardiographicimaging and Doppler studies,whenever feasible, in a laboratory experiencedwith thesetechniques. In some instances,it may be more realistic for the physician in practice to obtain this training as an aggregateof multiple blocks of time. TrainingSite It is optimal when training in echocardiographycan be obtained as part of a formal, full-time cardiology training program. This training program should have an establishedechocardiographiclaboratory run by a full-time physician-director who is experiencedin all phasesof echocardiography,and who has achievedat least Level 3 competence.Optimally, the echocardiography laboratory should be located within an active medical institution that has both inpatient and outpatient services, critical care and coronary care units, cardiac catheterization/angiographic facilities, a cardiac surgical program and an active emergency room.The echocardiography laboratory should perform echocardiographicstudies on at least 1,000patients per year, and shouldbe experiencedin M-mode, &dimensional and Doppler techniques. As novel developmentssuch as color Doppler flow imaging becomeavailable and clinically useful, the relevant techniques and clinical applications also should be incorporatedinto the training program.Familiarity with related special proceduressuch as contrastechocardiography,stressechocardiographyand invasive echocardiographictechniquesis also desirable. The range of patient problems and noninvasive findings seen in such a setting, and the availability of hemodynamic and anatomic data for comparison,should afford the physician-traineea broad exposureto the clinical applications of echocardiography. ContinuingEducation The techniquesand clinical applications of echocardiographyare evolving rapidly, and there is every reason to expect this evolution to continue in the future. Therefore, all physicians responsible for the performanceand interpretation of echocardiographic studies,whether they were trained aspart of a formal cardiology fellowship training program or obtained equivalent post-fellowship training, should maintain active and ongoingcontinuing educationin this field. They should seek to compare the quality, completeness and results of their echocardiographicstudies with those presentedin professional journals and at scientific meetings. Wherever possible, they should also assessthe validity of their findings in patients undergoingcardiac catheterization,cardiac surgeryor postmortem examination. A wide range of continuing medical educational programs is available to provide the practicing physician-echocardiographerwith ongoingupdatesin echocardiographictechniquesand applications.These programs also provide the physician with a mechanism for assessinghis or her skills and proficiency. However, short postgraduatecoursesand brief workshopsof 1 week or less,althoughwidely available and often of good quality, are not sufficient in scope or depth to constituteby themselvesadequatetraining in technical or interpretive skills. These courses and workshops are a meaningful supplement to formal training, and they may provide a useful overview of the field, a helpful framework for further learning, and a valuable exposureto new concepts.However, by themselves,they clearly do not provide the degree of experienceneeded to perform and interpret echocardiographic studies independently. In conclusion, optimal use of echocardiographic techniquesfor diagnosisand clinical decision-making July 1, 1987 is based on a great deal of theoretical knowledge, important technical abilities, and significant clinical experience with echocardiographic applications. Proper development of these skills requires substantial training, which optimally should be carried out under the guidance of an experienced physician-echocardiographer. We recommend 3 levels of training (introductory, intermediate and advanced] in echocardiography for cardiology fellows, and recommend that physicians who have already completed their fellowship training attain equivalent levels of expertise appropriate to their needs. We believe it ideal when this training is carried out as part of a formal cardiology training pyogram. Finally, we recognize that the guidelines we have proposed provide only a general framework for training in the rapidly evolving field of echocardiography. Thus, special expertise [beyond the guidelines recommended here) may well be needed for the physician who uses echocardiography for specialized applications such as complex congenital heart disease, transesophageal echocardiography or invasive studies. Acknowledgment: In preparing the current recommendations, we have tried to maintain consistency with previous documents that dealt with physician training in echocardiography, whenever that appeared appropriate. Accordingly, the current guidelines were formulated keeping in mind the reports of the Inter-Society Commission for Heart Disease Resources-Echocardiography Study Group,2 the American Society of Echocardiography Committee on Physician Training in Adult M-Mode and Two-Dimensional Echocardiography,l4 and the 17th Bethesda Conference: Adult Cardiology Training-Task Force IV: Training in Echocardiography.lg Similarities between the current report and these predecessors are unavoidable and intentional. References 1. Kirkendall WM. Feinleib M, Freis ED, Mark AL. AHA Committee Report. Recommendations for human blood pressure determination by sphygmomanometers. Circulation 1980;62:1146A-1155A. 2. Popp RL, Fortuin NJ, Johnson ML, Kisslo JA. Echocardiography Study group. Optimal resources for ultrasonic examination of the heart. Report of the Inter-Society Commission for Heart Disease Resources. Circulation 1982;65:423A-431A. 3. Gettes LS, Zipes DP, Gillette PC, Josephson ME, Laks MM, Mirvis DM, Scheinman MM, Sheffield LT, Wu D. Personnel and equipment required for electrophysiologic testing. Report of the Committee on Electrocardiography and Cardiac Electrophysiology, Council on CUnical Cardiology, The American Heart Association. Circulation 1984;69:1219A-1221A. 4. Adelstein SJ, Holman BL, Wagner HN, Zaret BL. Nuclear Medicine Study Group. Optimal resources for radioactive tracer studies of the heart and circulation. Report of the Intersociety Commission for Heart Disease Resources. Circulation 1984;70:525A-53612. THE AMERICAN JOURNAL OF CARDIOLOGY Volume 60 163 5. Zaret BL, Battler A, Berger HJ. Bodenheimer MM, Borer JS, Brochier M, Hugenholtz PG. Neufeld HN, Pfisterer ME. Report of the [oint lnternationol Society and Federation of Cardiology/World Health Organization Tosk Force on Nuclear Cardiology. Circulation 1984:70:768A-781A. 6. Graham TP, Brandenburg RO. Friedman WF, Higgins CR, Hoffman JIE. McNamara DG, Meyer RA, Sahn DJ, Schelbert HR. Steering Committee: 14th Bethesda Conference. Conference recommendations: noninvasive diagnostic instrumentation for assessment of cardiovascular disease in the young. JACC 1984;5:162S-1655. 7. Sheffield LT, Berson A, Bragg-Remschel D, Gillette PC, Hermes RE, Hinkle L, Kennedy H, Mirvis DM, Oliver C. Recommendations for standards of instrumentation and practice in the use of ombulotory electrocardiography. The Task Force of the Committee on Electrocardiography and Cardiac EJectrophysiology of the Council on Clinical Cardiology. Circulation 1985:71: 626A-636A. 8. Schlant RC, Blomqvist CG, Brandenburg RO, DeBusk R, Ellestad MN, Fletcher GF, Froelicher VG, Hall RJ. McAllister BD, McHenry PL. Ryan TJ, Sheffield LT. Subcommittee on Exercise Testing. Guidelines for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on assessment of cardiovascular procedures. JACC 1986;8:725-738. 9. Graham TP. Gessner IH, Friedman WF, Gersony WM, Gutgesell H, Horn AR, Jarmakani JM, Maron BJ, Rosenthal A, Uxark K, Vetter V, Williams RG, Yabek S. Recommendations for the use of laboratory studies for pediatric patients with suspected or proven heart disease. A Statement of the Committee on Congenital Cardiac Defects of the Council of Cardiovascular Disease in the Young of the American Heart Association. Circulation 1986;74:443A450A. 10. O’Rourke RA, Chattejee K, Dodge HT, Fisch C, Levine HJ, Pohost GM, Resnekov L. Subcommittee on Nuclear Imaging. Guidelines for clinical use of cardiac radionucfide imaging, December 1986. A report of the American College of Cardiology/American Heart Association Task Force on assessment of cardiovascular procedures. Circulation 3986;74:1469A-1482A. 11. Sahn DJ. DeMaria AN, Kisslo J, Weyman A. The Committee on M-Mode Standardization of the American Society of Echocardiography. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978;58:1072-1083. 12. Henry WL, DeMaria A, Gramiak R, King DL, Kisslo JA, Popp RL, Sahn DJ, Schiller NB, Tajik A, Teichholz LE, Weyman AE. Report of the American Society of Echocardiography Committee on Nomenclature and Standards in Two-Dimensional Echocardiography. Circulation 1980;62:212-217. 13. Bommer WJ, Shah PM, Allen H, Meltzer R, Kisslo J. The safety of contrast echocardiography. Report of the Committee on Contrast Echocardiography for the American Society of Echocardiography. JACC 1984;3:6-13. 14. Martin RP, Kisslo J, Quinones MA, Popp RL, Feigenbaum H, Tajik A], Hagan AD. Report of the American Society of Echocardiography Committee on Physician Training in Adult M-Mode and Two-Dimensional Echocardiography. American Society of Echocardiography: April 1982. 15. Filly K, Hagen-Ansert S, Hagan A, Carney D, Kisslo J, Christie L, Korfbagen J. Report of the American Society of Echocardiography Committee on Education and Training of the Echocardiographer (Cardiac Sonographer). American Society of Echocardiography: August 1982. 16. Henry WL, DeMaria A, Feigenbaum H, Kerber R, Kisslo J, Weyman AE, Nanda N, Popp RL, Sahn D, Schiller NB, Tajik AJ. Report of the American Society of Echocardiography Committee on Nomenclature and Standards: identification of myocardial wall segments. American Society of Echocardiography: November 1982. 17. Sahn DJ, Baker DW, DeMaria A, Gessert J, Goldberg SJ, Gutgesell H, Henry W, Martin R, Popp R, Silverman N, Snider R, Stevenson G. Report of the American Society of Echocardiography Doppler Standards and Nomenclature Committee: Recommendations for terminology and display for Doppler echocardiography. American Society of Echocardiogrophy: August 1984. 18. Silverman NH, Sahn DJ, Allen HD. Report of the Standards Committee on Nomenclature of the Society of Pediatric Echocardiography and the American Society of Echocardiography: Nomenclature for cardiac septa. American Society of Echocordiography: January 1986. 19. DeMaria AN, Crawford MH, Feigenbaum H, Popp RL, Tajik AJ. Task Force IV. Training in echocardiography. Report of Bethesda Conference 17: Adult Cardiology Training. JACC 1986;7:1207-1208.