Echocardiography Education with Simulation Training
Echocardiography Education with Simulation Training Athanasios Tsoukas, MD, PhD, FESC
Educational curricula in Echocardiography traditionally include theoretical knowledge and practical hands-on experience, initially obtained by performing supervised studies on real patients in a clinical setting. Competence in echocardiography requires a deep understanding of cardiac anatomy, physiology, pathophysiology and haemodynamics, which must then be correlated to the corresponding ultrasound images as well as technical aspects including ultrasonic physics. The learning curve for a trainee to become skilled and self-sufficient, takes a long time. Moreover, experience requires familiarisation with various clinical scenarios and cardiac conditions, which is lengthening the duration of the procedures; it is accompanied by reduced productivity, potential patient safety concerns and considerable stress for the patient and the fellow in training.
Nowadays there is a strong recommendation for using simulators in clinical practice. Echocardiography skills should be performed and learned in a simulation environment prior to undertaking them on real patients. Simulators is a modern way to learn normal and abnormal cardiac anatomy and function in a safe digital environment, promoting experience with safety of the patients.
Education using simulators customary in certain fields including aviation, space exploration, Formula 1 and Moto GP drivers for training purposes in complex settings and procedures. This method has been postulated as having the potential to assist trainees develop technical skills to expert level before undertaking them in reality, providing a safe environment in which they are allowed to make mistakes and learn from them, review performance and have the ability to stop the procedure and restart any parts of the training necessary.
Advantages include elimination of trainee stress, elongation of the time procedure as needed particularly in techniques such as transesophageal echocardiography that require practical skills, acquisition of optimum quality images, practise in a variety of clinical cases and ongoing education. Trainees can perform a complete echo study with measurements and calculations, inserting all data and issuing a final report at the end of the examination. Logistics of the system permit for every trainee doctor to complete a personal logbook with all his studies on the simulator, for further evaluation and accreditation in the future.
Simulation training is not new to medicine. Anatomical models were created for practice in cardiopulmonary resuscitation. The first cardiovascular simulators were based on computer technology and provided cardiac anatomy with palpable pulse and areas for auscultation. These allowed medical students to experience some of the findings from clinical examination for first time in a mannequin. Modern technology allows the creation of complex anatomical, physiological and pathophysiological systems programmed to respond to the user. Specifically in the field of Cardiology, a number of simulators for echocardiography, coronary angioplasty, pacing, transcatheter aortic valve replacement and peripheral vascular interventions are available.
Echocardiography simulators are used both in Transthoracic and Transesophageal Imaging. Simulation-based learning offers to the trainee a high quality examination, in a low stress and low pressure environment with a functioning realistic probe and a realistic mannequin similar to living patients. The simulator enables a real time 3D reconstruction of the cardiac anatomy in a variety of clinical scenarios. In every case there is a simultaneous anatomically accurate and interactive 3D heart, so trainees can relate the anatomic to the ultrasound imaging. This 3D heart model can be rotated and sliced in any direction and the intracardiac structures can be highlighted.
Realistic transthoracic (TTE) scanning can be obtained and users can learn how to perform the standard echocardiographic exams in sequential images similarly to a real patient exam. As in ultrasound machines, simulators have modules for M-mode, biplane, colour, pulsed wave and continuous wave doppler in all regions. A software package for measurements and calculations is also available online. The system includes the gold standard imaging views for each of transesophageal (TEE) planes, side by side with 3D cardiac anatomy images, using the realistic TEE probe with controls for ante and retroflexion, lateral flexion and omniplane rotation.
Training is obtained in a wide range of clinical cases, including normal heart and lungs, various disease states and key cardiac devices. Coronary artery disease, valvular diseases, cardiomyopathies, pericardial diseases, cardiac tamponade, congenital heart disease, acute aortic syndromes, prosthetic valves, cardiac devices, pulmonary embolism, pneumothorax, as well as o lot of clinical cases and scenarios are included in the educational program of the simulation system. Testing platform allows tutors to create standardized or customized tests for students and is an effective assessment tool that can easily adapted to any training need.
Simulation equipment and modules alone cannot offer a complete education. Even tutors will require specialized training in equipment use and techniques, which requires skills not necessary for other forms of teaching. They need support from experienced educators to run successful simulation programs. The technology of simulation is rapidly progressing, offering last generation and high fidelity devices, more cardiac diseases and clinical scenarios, and advanced modules including current minimally invasive procedures, such as TAVI, mitral clip, left atrium appendage occlusion with device, lung scan in Covid patients.
Additionally there is a growing simulation faculty, with national and international societies, conferences and peer reviewed publications. American Society of Echocardiography and European Society of Cardiovascular Imaging schedule training recommendations to standardize the use of these new learning and training methods, separately from the existed guidelines for Transesophageal and Transthorasic Echocardiography.
Simulation in Cardiology and Echocardiography is expanding rapidly due to advances in digital technology. A new way of training is now available in a safe environment, without any risk for the patient, extended training hours and ability for more progressive skill acquisition and maintenance. In the near future, possibly before any healthcare professional performs a skill on a patient, should have the opportunity to perform the same skill in a simulation device. This is especially important as exposure to patients by junior doctors and training hours are reduced. Simulation assures that cardiologists in training have reached the minimum standards of competence before performing procedures on patients as well as experienced operators further specialize in new technologies.
In conclusion, simulators in Echocardiography offer a full education program in Transthoracic (TTE) and Transesophageal Echocardiography (TEE) for trainees in Cardiology, Cardiologists, Anesthesiologists, and all doctors who are interest in the field of Echocardiography. The software provides side-by-side best quality 3D anatomical images, echo views in virtual reality and a wide range of cardiac diseases. Simulator allows realistic probe positioning for both TTE and TEE echo. TEE probe offers all the authentic controls of a real probe and accurate enables real time anatomical and ultrasound views. Colour, PW and CW Doppler modalities, 2D and Doppler measurements are also available with the tools for a quantitative assessment. Technology in simulation is rapidly progresses and modules for 3D studies are now under comprehensive evaluation, and will be suitable for use in the daily clinical practice at the end of this year.
