Cardiothoracic fellowship case requirements, explained.
Every case requirement ACGME sets for adult cardiothoracic anesthesiology fellows, how a TEE is logged in ACGME’s Case Log System, and how the 150 and 300 line up with the National Board of Echocardiography’s certification. From ACGME’s Program Requirements, effective September 3, 2025, with the clause for every line.
Every requirement at a glance
All of these are in Section 4.11 of ACGME’s Program Requirements for Adult Cardiothoracic Anesthesiology (pages 24 to 26).
| Requirement | Minimum | What it says |
|---|---|---|
| Cardiac surgical procedures§4.11.a.1 | 100 | Any cardiac surgical procedure. |
| Requiring bypass§4.11.a.1 | 50 | Part of the 100: procedures requiring cardiopulmonary bypass. |
| Valve repair or replacement§4.11.a.1.a | 30 | Aortic and/or mitral valve repairs or replacements. |
| Mitral§4.11.a.1.a | 10 | At least 10 of the 30. |
| Aortic§4.11.a.1.a | 10 | At least 10 of the 30. |
| Requiring bypass§4.11.a.1.a | 20 | At least 20 of the 30. |
| Myocardial revascularization§4.11.a.1.b | 20 | With or without bypass. |
| Breadth§4.11.a.1.c | 2 of 4 | Experience in two or more of: adult congenital correction or revision; heart and lung transplantation; circulatory assist (left heart bypass, VADs, balloon pumps, ECMO); electrophysiology procedures under general anesthesia. |
| Non-cardiac thoracic surgery§4.11.a.2.a | 15 | Anesthetic management of patients undergoing non-cardiac thoracic surgery. |
| Thoracic aorta§4.11.a.2.b | 5 | Endovascular and/or open repair of the thoracic aorta. |
| As primary anesthesia provider§4.11.b.1 | 35 | Cases where the fellow is the primary anesthesia provider (see the rules below). |
| Peri-operative TEE§4.11.e | 300 | Examinations performed and/or reviewed. |
| Performed by the fellow§4.11.e.1 | 150 | Part of the 300: examinations the fellow performs under supervision. |
ACGME Program Requirements for Graduate Medical Education in Adult Cardiothoracic Anesthesiology, interim revision effective September 3, 2025, Section 4.11. For breadth, ACGME names the four categories and asks for two or more; it doesn’t set a number of cases within each.
Log a case in a sentence and Anesto counts it toward every fellowship requirement it meets, keeps a TEE log with the 150 and 300 counters, and sends cases and TEEs to ACGME from your phone. Free for fellows.
The rules around the numbers
Being the primary anesthesia provider
For the 35 primary cases, the fellow “should not be supervising a resident or student” (§4.11.b.1.a). A resident or second fellow may still perform a TEE during one of those cases, under faculty supervision (§4.11.b.1.b).
Time, not just cases
- At least six months of clinical anesthesia in cardiac and thoracic care (§4.11.a).
- At least one month in a cardiothoracic intensive care unit (§4.11.c).
- Two clinical elective rotations of at least two weeks each; a research project can stand in for one or two months of electives (§4.11.d, 4.11.d.2).
- Advanced peri-operative echocardiography education, completed successfully (§4.11.e.2). No number is attached.
How a TEE is logged in ACGME
ACGME’s instructions say each TEE case is entered twice in the Case Log System:
- Once under Adult Cardiothoracic Anesthesia, with the procedure and diagnosis.
- Once under Echocardiography Participation, with your level of participation in the exam.
Both entries need the same Case Date and Case ID so ACGME groups them as one case. If different attendings supervised the anesthetic and the echo, each entry can name its own attending; the date and Case ID still have to match.
ACGME, “Instructions for Logging a TEE Case in the ACGME Case Log System” (Review Committee for Anesthesiology, 3/2025), pages 1 to 3.
The 150 and 300, and the NBE
ACGME sets the TEE numbers “such that they meet NBE requirements for certification in advanced peri-operative TEE” (§4.11.e). So the same two numbers are an ACGME requirement for your fellowship and the National Board of Echocardiography’s bar for Advanced PTEeXAM certification, through its supervised training pathway:
- 300 complete peri-operative TEE examinations studied under appropriate supervision.
- At least 150 of them comprehensive intraoperative exams you personally perform, interpret and report, with the supervising physician present for all critical parts and immediately available throughout.
- The rest are acquired and reviewed at an institution where you’ve performed TEEs under supervision.
- The supervised training has to be completed in two years or fewer, and TEEs from your core anesthesiology residency don’t count.
- “Peri-operative” means intraoperative, post-operative in the same hospitalization, or pre-operative in a patient having surgery in that hospitalization. A diagnostic TEE before a cardioversion, for example, doesn’t count.
The NBE also has a practice-experience pathway for people certifying without this kind of fellowship. It uses 300 and 150 too, but under different rules (four consecutive years, at least 50 a year), so don’t mix the two up.
National Board of Echocardiography, Application for Certification: Adult Advanced Perioperative TEE (Advanced PTEeXAM), Requirement 5, page 5.
Sources
- ACGME Program Requirements for Graduate Medical Education in Adult Cardiothoracic Anesthesiology, interim revision effective September 3, 2025. Section 4.11, pages 24 to 26.
- ACGME: Instructions for Logging a TEE Case in the ACGME Case Log System, Review Committee for Anesthesiology, 3/2025.
- National Board of Echocardiography: Advanced PTEeXAM, and its certification application (Requirements 4 and 5).
ACGME’s and the NBE’s documents are the authority; if anything here differs from them, they win, and your program has the final word on how your cases are credited. Anesto is not affiliated with or endorsed by the ACGME or the National Board of Echocardiography.