Welcome to the Machine: The Role of Online Simulation in TEE Training

Published:November 19, 2022DOI:
      While the use of transesophageal echocardiography (TEE) for diagnosis and management of patients outside of the cardiac operating room has gained increased application and importance in recent years, there remains a significant barrier in accessing the training required to implement its use widely.1 The American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) provide clear guidelines for obtaining a complete exam, with the National Board of Echocardiography (NBE) producing the requisite standardized exam and defining the clinical experience necessary for certification in basic or advanced perioperative echocardiography. There is a concern, however, that those learners who have yet to obtain extensive clinical experience with TEE tend to focus their learning on memorization of the basic recommended views without understanding the intricacies of the relationship between cardiac three-dimensional (3D) anatomy and the TEE ultrasound beam.2,3 Simulation-based education has shown some promise in educating learners new to echocardiography, and could potentially address the issues surrounding memorization, without a true understanding, of the recommended echocardiographic views.4 Most current simulation-based training techniques rely on a dummy TEE probe with a mannequin, along with a computer screen to replicate standardized TEE views with or without pathology. These systems are integrated into hands-on didactic sessions at many academic medical centers; however, there remains the need for supplemental tools that will serve as a useful adjunct to in person TEE instruction as well as provide educational opportunities to those in other practice settings who have a desire to learn perioperative TEE.
      Arango et al. describe the development of an education tool consisting of an interactive online TEE simulator that provides simulation-based teaching, while also improving the accessibility of TEE education.4 Their system incorporates 3D human heart models, designed with the goal of providing a learning device to teach the nuances of cardiac 3D anatomy that can also be accessed from anywhere, at any time, by anyone. The images in the simulator are based on MRI scans of human heart specimens that were deemed unfit for orthotopic transplantation and donated to undergo a preservation process and subsequent high-resolution, computed tomography (CT) imaging. The CT slices were then summed to create a 3D model of the heart that could interact with a computer-generated representation of the TEE probe. On the user dashboard, there is a central image of the heart and surrounding anatomy, with a steerable TEE probe in the esophagus that projects an ultrasound plane which can be manipulated by the user. The correlating two-dimensional (2D) ultrasound image is displayed alongside the 3D anatomy, allowing for correlation of the 2D echocardiographic image with corresponding 3D cardiac anatomy. A menu of ASE-recommended views are provided, from which the learners can manipulate the probe to see adjacent planes or obtain other standardized views.
      The authors have made this tool available for free to access online, thereby creating an easy to distribute, widely available, simulation-based, educational tool. Despite this simulation model not having the quantitative data to demonstrate its efficacy, there is evidence from prior studies that simulation can be a highly effective method of TEE training.5-8 Of note, a 2021 meta-analysis of randomized control trials comparing simulator TEE training to non-simulator training found the former to result in significantly higher levels of skill and knowledge retention in trainees.5 However, it must be noted that the model the authors describe is not without its limitations. First, the ability represent both normal anatomic variability as well as common pathology is limited by the cadaveric hearts used to develop the 3D model. Additionally, any form of online simulator will be hampered by the fact that there is no hands-on experience with safe probe insertion, physical probe manipulation, “knobology,” or image optimization.
      Ultimately, despite its shortcomings, this tool is most impactful in that it serves as a freely accessible model of simulation-based TEE education. There is accumulating data on the clinical usefulness of TEE in areas such as non-cardiac operating rooms, liver transplantation, surgical and medical intensive care units, and the emergency department.9,10 If TEE is to be more widely applied, however, we must recognize that a gap exists in providing education to those who may not have, or have only limited, access to hands-on TEE experience. While the authors of this editorial have doubts that online simulation alone could ever provide enough clinical expertise to widely implement TEE usage without additional training, it has great promise when viewed as a foundation for, or supplement to, more time-limited, focused, clinical experience. The widespread adoption of TEE imaging will only occur when the barriers to education are significantly lowered without compromising patient safety or practitioner accuracy, and the online tool created by Arango, et al. is a step in this direction.
      Declarations of Interest


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      Reeves ST, Finley AC, Skubas NJ, et al: Council on Perioperative Echocardiography of the American Society of Echocardiography; Society of Cardiovascular Anesthesiologists. Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013 May;26(5):443-56
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      Linked Article

      • A Free-Access Online Interactive Simulator to Enhance Perioperative Transesophageal Echocardiography Training Using a High-Fidelity Human Heart 3D Model
        Journal of Cardiothoracic and Vascular Anesthesia
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          The clinical uses of perioperative transesophageal echocardiography have grown exponentially in recent years for both cardiac and noncardiac surgical patients. Yet, echocardiography is a complex skill that also requires an advanced understanding of human cardiac anatomy. Although simulation has changed the way echocardiography is taught, most available systems are still limited by investment costs, accessibility, and qualities of the input cardiac 3-dimensional models. In this report, the authors discuss the development of an online simulator using a high-resolution human heart scan that accurately represents real cardiac anatomies, and that should be accessible to a wide range of learners without space or time limitations.
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