Introduction to TEE using Heartworks Echocardiography Simulator Steven M. Ewer, MD Assistant Professor Division of Cardiovascular Medicine University of Wisconsin School of Medicine & Public Health Version last updated: July 26, 2013
Objectives: Using this echocardiography simulation technology, first year cardiology fellows and other trainees will gain an introduction to the TEE examination, setting the foundation for the performance of this procedure later in their training. Trainees will use this software to develop a comprehensive understanding of 3D cross-sectional anatomy of the normal heart and associated vascular structures. They will understand the degrees of freedom allowed by a standard TEE probe. Trainees will first be able to generate a set of standard TEE views with a virtual probe. Once achieved, trainees will then generate the same images using the probe simulator, developing the hand-eye coordination required to perform studies in real patients. The Clinical Simulation Program Facility: The simulation facility is located in the H6 module on the 1 st floor. Access is available 24/7 as long as the equipment is not in use. The staff will activate your badge upon request for after-hours access via H6 111. Sign in and out using the log at the workstation. The staff can assist with any questions regarding the software. Please use caution when handling the probe simulator just like a real probe, it is a delicate and expensive piece of equipment! Heartworks Simulator Tips: See last page for more detailed software instructions. Power on the hard drive. Default will be a normal exam, but you can select various pathologic states as well. Click Launch Heartworks. A small plug icon will activate or deactivate the probe simulator. The virtual probe will be active when the probe simulator is not. Alt-Left click will allow rotation of the schematized heart. Hold down space bar to pause animation. Home key resets schematic to original settings. Slicing modes: None will cause the heart to appear whole. Ultrasound will show cut-away views at the plane of the ultrasound beam. Auto camera mode will create an image similar to Ultrasound, but with the transducer at the top of the screen and the US plane flush with the screen. This view will orient the heart as you would see it during a real TEE exam. The simulator does not yet have capability for color or spectral Doppler. Power off when finished (no need to exit out of anything).
Part 1: TEE Degrees of Freedom 1. Select slicing mode none. 2. Observe how the probe position changes as you adjust depth within the esophagus. 3. Observe how the imaging plane changes position as you rotate (twist) right/left. 4. Observe how the imaging plane changes as you adjust the angle. 5. Observe how the probe position changes with flexion/retroflexion. 6. Repeat 2-5 concentrating now on the simulated TEE image and how it changes with each maneuver. 7. With the angle at 0 o, be able to adjust the TEE image right and left on the screen. 8. Do the same at 90 o. How is it different? What would happen at intermediate angles? Part 2: Normal Cross-sectional Anatomy Go now to the slide show called Ewer. Each animated slide will show a standard TEE view along with the corresponding schematic illustrating the cross section from which the image is generated. For each slide, pay attention to probe position, location of the imaging plane and probe settings that allow them both. Feel free to adjust the probe settings to see how this changes the images. 1. Home view 4 chamber Often the first view obtained. Easy to find at the mid-esophageal level with all probe settings neutral. Shows LV (inferoseptal and anterolateral walls), MV, LA, RA, atrial septum. 2. Modified 4 chamber for RV From the home view, increase depth and twist to right to optimize imaging of RV and TV. 3. MV bicommissural view Understand how 2 commissures (P3 A2 P1) are created because of the curved MV coaptation. 4. 2 chamber Note LV (anterior and inferior walls) and MV. 5. 3 chamber Similar to the apical 3 chamber view on TTE, this plane cuts through both the MV and AV and shows the anteroseptal and inferolateral walls of the LV. 6. AV short axis Similar to the parasternal short axis TTE view through the AV. Adjust the depth slightly to go between the base of the AV and the leaflet tips. Name the leaflets.
7. AV long axis Shows the right and non-coronary AV leaflets, LVOT, aortic root. Decrease depth and twist to right to bring in more of the ascending aorta. 8. RV inflow/outflow Shows tricuspid and pulmonic valves. 9. PA long axis Higher up in the esophagus, this view shows the main PA and bifurcation and allows for pulmonic valve Doppler. This is another opportunity to view the pulmonic valve, which may be useful if the RV inflow/outflow view is suboptimal (i.e. in the presence of a prosthetic AV). 10. Bicaval view LA, RA (including RA appendage), atrial septum, SVC, IVC. Adjust depth to see more of IVC or SVC. 11. Transgastric short axis Excellent view for LV function. Adjusting depth will bring in more basal or apical segments. 12. Transgastric 2 chamber LV and MV. 13. Transgastric 3 chamber One of two opportunities to Doppler the AV with TEE. 14. Deep transgastric LV outflow. The other AV Doppler opportunity. Probe is essentially at the apex. 15. Descending aorta. Probe is twisted far left. The entire descending thoracic aorta can be seen. 16. Aortic arch. Seen in long axis high in esophagus.
Part 3: TEE Image Generation with the Virtual Probe This table comprises the core elements of a complete TEE study along with the probe settings needed to acquire images. Use the toggle auto camera on setting while generating the desired image using the virtual probe. Use the mouse to adjust depth, angle, twist, and flexion. Compare the 3D cross section animation schematic with the TEE image. Depth corresponds to distance from teeth (indicated by a line on the virtual probe). View Depth Angle Twist Flexion Home 4 chamber 32 0 - Slight - Modified 4 chamber for RV 35 0 R Slight - 2 chamber 32 70 - Slight - 3 chamber 35 120-0 AV long axis 32 120 Slight R 0 AV short axis 27 35 Slight R 0 TV 35 0 R 0 RV inflow/outflow 32 60 R Slight + TV 35 120 R 0 PA 25 0 Slight R 0 Atrial septum 32 0 R 0 Bicaval 28 90 R Slight - LA appendage 50 25 50 Slight L Slight - LA appendage 90 25 90 L Slight - LA appendage 120 24 120 L Slight - Left pulmonary veins 28 120 L 0 Right pulmonary veins 30 40 Far R 0 Transgastric short axis LV 50 0-0 Transgastric short axis RV 50 0 R 0 Transgastric 2 chamber LV 50 90-0 Transgastric long axis RV 50 90 R 0 Transgastric 3 chamber 47 110 R + Deep transgastric AV 58 0 R ++ Descending aorta 30 0 Far L 0 Aortic arch 21 0-0
Part 4: TEE Image Generation with the Probe Simulator Use the plug icon to activate the probe. Position the mannequin in front of the screen, head to your left if you are right-handed, or head to your right if you are left-handed. Insert probe into the mannequin (this part does not simulate reality very well). With the slicing mode deactivated, repeat the exercises in Part 1, now using the hand-held controls on the probe. Next, use the toggle auto camera on setting and go through the table in part 3 again to generate the same TEE images. Rather than memorizing settings for each view, try to understand (with the help of the anatomical schematic) what changes are required to take you from the current image to the desired view.
Power On Power on computer - push button on desk top computer Accept User Terms & Conditions Select pathologies Launch Heartworks Choose Pages - Select start-up pages (from drop down menu) Navigating 3D Heart Press & hold Alt + Lt mouse button Orbits (rotates heart) Press & hold Alt + Rt mouse button Tracks (zooms in & out) Press & hold Alt + middle roller button PAN Press & hold Alt + Both Lt & Rt mouse button Rolls HOME button on keyboard will reset and take you back to the starting point Highlighting Structures Press & hold SPACEBAR + hover mouse over heart (temporary label heart) Press & hold SPACEBAR +Lt. mouse button for more information Press & hold SPACEBAR + Rt mouse button (removes the selected structure) Press & hold SPACEBAR + middle roller button (shows default view for selected structure) HOME button on keyboard will reset and take you back to the starting point Selecting TEE Standard Images Choose page (Go to toolbar on Lt. Select Start-Up Pages ) Select TEE Standard imaging planes (20 standard views) Select mid-esophageal - 4 chamber view to start Using Probes Select Start-up pages Click on activation icon ( on toolbar Haptic Interface - plug-in icon) Open next drop down list (choose TEE or TTE start-up) TEE Probe Black Wheel on TEE probe Clockwise is Anti-Flection Counter Clockwise is Retro-Flection TTE Probe - Place probe on manikin chest firmly to find views EXIT application (also - to get to other pathologies) Advanced Techniques Camera Slicing Mode Select manipulator mode on top toolbar - resets plane Press & hold Shift + Lt removes some of outer heart to see internal view drag mouse to slice more or less removed. Press & hold Shift + Rt rotates the slice plane Click on the Invert icon (on top toolbar) inverts the image to the opposite side of heart