To the Editor,
Recent research indicates that transthoracic echocardiography (TTE) during resuscitation may cause delays in chest compressions, potentially impacting the quality of resuscitation.1, 2 Additionally, resuscitation equipment, such as mechanical compression devices and defibrillators, can interfere with TTE image acquisition and interpretation.
Transesophageal echocardiography (TEE) offers a solution to these limitations by providing real-time cardiac imaging without interrupting chest compressions. However, TEE is costly, invasive, and requires advanced operator skills. To address these challenges, the American College of Emergency Physicians has issued policy recommendations for TEE use during cardiac arrest. These include 2–4 h of specialized training, performing at least 10 simulated examinations, and assessment by certified operators.3
In this context, a 4-hour TEE curriculum for cardiac arrest using the HeartWorks simulator (Intelligent Ultrasound, United Kingdom) was developed. The curriculum included 1-hour didactic sessions, 2-hour small-group hands-on training (instructor-to-trainee ratio of 1:3) utilizing clinical scenarios, and 1-hour post-course assessments. The clinical scenarios focused on key conditions during resuscitation such as hypovolemia, cardiac tamponade, pulmonary embolism, aortic dissection, and regional wall motion abnormality (Supplementary File). Expert instructors, each with experience performing TEE in more than 100 cases, guided the training.
The effectiveness of the curriculum was assessed in a prospective study conducted from August 2023 to July 2024. Twenty-one emergency medicine residents with no prior TEE experience participated. The study was approved by the hospital's Institutional Review Board (202211107RINB) and registered at ClinicalTrials.gov (NCT06567912). Written informed consent was obtained from all participants.
Performance metrics included standard view acquisition (ME4C, MELAX, UE, TGLAX) assessed using a 5-point Likert scale and image diagnostic accuracy (correct = 1, incorrect = 0). These were evaluated during the initial assessment and a 3-month recall assessment. Results were compared using the Wilcoxon signed-rank test, and real-time feedback was provided following each assessment.
Although no TEE procedures were performed on real patients after training, residents demonstrated sustained skill performance [initial vs. recall, 4 (4) vs. 4 (3.5–5), p = 0.487] and diagnostic accuracy [1 (1) vs. 1 (1), p = 0.162]. Notably, there were no significant differences between senior and junior residents (1st- and 2nd-year residents). Our findings suggest that TEE skills can be effectively learned and retained through simulation-based clinical-scenario training, even in the absence of real-world practice.
TEE is a relatively new point-of-care ultrasound (PoCUS) modality for managing patients with cardiac arrest, with limited evidence on effective teaching methods for emergency physicians. Unlike other PoCUS applications, teaching TEE using healthy volunteers is impractical. Simulation-based training with high-fidelity simulators has proven effective for teaching resuscitative TEE. However, most studies focus on standard view acquisition, with limited use of clinical scenarios.4, 5 Our findings highlight the value of integrating clinical scenarios with high-fidelity simulators to help novices develop and maintain TEE skills without clinical experience.
Challenges remain in applying these skills to real resuscitation scenarios, where conditions are more complex and stressful. Further research is needed to validate the curriculum’s effectiveness and its impact on real-world clinical performance.
Grant or financial support
National Science and Technology Council (NSTC 112–2410-H-002–171).
CRediT authorship contribution statement
Tai-Yuan Chen: Data curation, Formal analysis. Yi-Chia Wang: Investigation, Resources, Supervision. Wan-Ching Lien: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft, Writing – review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.resplu.2024.100861.
Appendix A. Supplementary material
The following are the Supplementary data to this article:
References
- 1.Huis In 't Veld M.A., Allison M.G., Bostick D.S., et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95–98. doi: 10.1016/j.resuscitation.2017.07.021. [DOI] [PubMed] [Google Scholar]
- 2.Clattenburg E.J., Wroe P., Brown S., et al. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65–68. doi: 10.1016/j.resuscitation.2017.11.056. [DOI] [PubMed] [Google Scholar]
- 3.ACEP. Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest. In: Physicians ACoE, editor.2017.
- 4.Chenkin J., Jelic T., Hockmann E. Optimizing simulator-based training for emergency transesophageal echocardiography: A randomized controlled trial. AEM Educ Train. 2023;7 doi: 10.1002/aet2.10845. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Damp J., Anthony R., Davidson M.A., Mendes L. Effects of transesophageal echocardiography simulator training on learning and performance in cardiovascular medicine fellows. J Am Soc Echocardiogr. 2013;26 doi: 10.1016/j.echo.2013.08.008. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.