Cardiovascular simulation has emerged as a multifaceted learning tool with important applications in transesophageal echocardiography (TEE). About a decade ago when I was a cardiology fellow, simulators were not commonly used. As a new trainee, my first few TEE experiences involved observation, which took some maturity to appreciate. For technical preparation, I found an online simulation program that was helpful in visualizing transducer movement but involved dragging a mouse – not handling a probe. As TEE opportunities increased, there were certain attending physicians that fellows appreciated because they gave them enough time to learn. Attending physicians who could teach exactly how to manipulate the probe were very helpful.

When I transitioned from learner to teacher, I wanted to give trainees the time that they needed during TEE – sometimes even forsaking a view or two. Over time, I have come to appreciate that insufficient preparation for the hands-on experience not only influences procedural efficiency and quality but also limits a trainee's learning experience. Furthermore, a variety of complications can occur during TEE, even in the hands of experienced practitioners. Therefore, establishing basic competencies in a controlled, simulation setting is an opportunity to reduce procedural risk.

The COCATS training statement on echocardiography acknowledges the potential role of TEE simulation under two circumstances. First, the statement identifies simulation as a supplemental training method to enhance procedural skills. Echocardiography skills advancement through simulation, for example, may be increasingly relevant for lower volume intensivists as data accrues that point-of-care TEE has potential to change clinical management, particularly in the critically ill patient. A second role for TEE simulation is as an evaluation tool to assess basic competencies in instrument use and image interpretation. For example, as part of its physician certification process, the British Society of Echocardiography has incorporated a TEE skills practical, typically conducted on a simulator with an assessor present.

At the Malcolm Randall VA Medical Center, a well-established TEE simulation program has been implemented in concert with the University of Florida. Simulation allows cardiology fellows to participate in TEEs from the beginning of their training. There are additional TEE simulation programs designed specifically for anesthesia or critical care trainees. In all of the aforementioned training programs, simulation is a high yield option for trainees who are trying to acquire multiple knowledge sets at once with limited time for self-study. New cardiology trainees complete 2-3 one-hour TEE simulation sessions over approximately three months. These instructional sessions use a core group of imaging faculty for one-on-one teaching. Over the course of training, fellows participate in a didactic curriculum based on the ASE/SCA guidelines for performing TEE. Fellows also take quizzes from the Toronto General Virtual TEE training modules to establish a metric of their basic knowledge and complete surveys about their skill level and confidence before and after the training.

The simulator used at the Malcolm Randall VA Medical Center is made by HeartWorks. The version used is dual TEE/TTE simulator and has both normal heart and pathology applications. Trainees appreciate the ability to track transducer position and orientation real-time in planar views as is seen by TEE, as well as in a 3D anatomic view. Alternative TEE simulation systems are available through other vendors, as outlined in a review in Echocardiography along with a general discussion on simulation.

Some TEE simulation programs use vendor-specific standardized skill assessments; a trainee completes these independently with subsequent review of their images and answers with an instructor. In contrast, the Malcolm Randall VA Medical Center program designed its own assessment tool, which is administered by an instructor at the beginning and end of training with real-time feedback. This skills check assesses related skillsets such as the views required to assess mitral regurgitation or complete a pre-atrial fibrillation ablation evaluation. There are two main skillsets assessed. First, the trainee should be able to acquire the images easily in each skillset category within a predetermined amount of time. Second, the trainees should be able to recognize key structures, including pathologies. During the final session, unknown pathologies such as aortic dissection or a flail mitral leaflet are presented. The diagnosis is determined as fellows work through their skillsets. After completing their training, fellows have the opportunity to perform a comprehensive TEE session with their instructor in the context of clinical care.

TEE simulation makes me a better educator by removing constraints of the clinical environment. Standardizing the TEE simulation experience assures that trainees exhibit basic competencies before they engage in bedside experiences. Incorporating pathology augments the level of learning engagement even as trainees accrue experience. Of course, simulation is not perfect. The intubation experience could "feel" more realistic and a greater variety of pathologies would engage clinicians that are more advanced. Importantly, simulation also requires a substantial financial investment. The cost of starting up a cardiac ultrasound simulation program ranges from $50,000 to $150,000 for equipment. Nonetheless, the investment in cardiovascular ultrasound simulation is worth considering, particularly if there are multiple beneficiaries within training programs or across specialties.

This article was authored by Anita Wokhlu, MD, cardiologist at the University of Florida and Malcolm Randall VA Medical Center in Gainesville, FL.