OBJECTIVES: Web and simulation technology may help in creating a transesophageal echocardiography (TEE) curriculum. The authors discuss the educational principles applied to developing and implementing a multimodal TEE curriculum. DESIGN AND SETTING: The authors modified a pilot course based on principles for effective simulation-based education. Key curricular elements were consistent with principles for effective simulation-based education: (1) clear goals and carefully structured objectives, (2) conveniently accessed, graduated, longitudinal instruction, (3) a protected and optimal learning environment, (4) repetition of concepts and technical skills, (5) progressive expectations for understanding and skill development, (6) introduction of abnormalities after understanding of normal anatomy and probe manipulation is achieved, (7) live learning sessions that are customizable to meet learner needs and individualized proctoring in skill sessions, (8) use of multiple approaches to teaching, (9) regular and relevant feedback, and (10) application of performance and compliance measures. PARTICIPANTS: Fifty-five learners participated in a curriculum with web-based modules, live teaching, and simulation practice between August 2011 and May 2013. CONCLUSION: It is possible to develop and implement an integrated, multimodal TEE curriculum supported by educational theory. The authors will explore the transferability of this approach to intraoperative TEE on live patients.

BACKGROUND: Transesophageal echocardiography (TEE) is a complex endeavor involving both motor and cognitive skills. Current training requires extended time in the clinical setting. Application of an integrated approach for TEE training including simulation could facilitate acquisition of skills and knowledge. METHODS: Echo-naive nonattending anesthesia physicians were offered Web-based echo didactics and biweekly hands-on sessions with a TEE simulator for 4 weeks. Manual skills were assessed weekly with kinematic analysis of TEE probe motion and compared with that of experts. Simulator-acquired skills were assessed clinically with the performance of intraoperative TEE examinations after training. Data were presented as median (interquartile range). RESULTS: The manual skills of 18 trainees were evaluated with kinematic analysis. Peak movements and path length were found to be independent predictors of proficiency (P 0.01) by multiple regression analysis. Week 1 trainees had longer path length (637 mm [312 to 1,210]) than that of experts (349 mm [179 to 516]); P 0.01. Week 1 trainees also had more peak movements (17 [9 to 29]) than that of experts (8 [2 to 12]); P 0.01. Skills acquired from simulator training were assessed clinically with eight additional trainees during intraoperative TEE examinations. Compared with the experts, novice trainees required more time (199 s [193 to 208] vs. 87 s [83 to 16]; P = 0.002) and performed more transitions throughout the examination (43 [36 to 53] vs. 21 [20 to 23]; P = 0.004). CONCLUSIONS: A simulation-based TEE curriculum can teach knowledge and technical skills to echo-naive learners. Kinematic measures can objectively evaluate the progression of manual TEE skills.

BACKGROUND: Selectively flexible rings, Colvin-Galloway (CG) Future and Carpentier-Edwards (CE) Physio II, are used for annuloplasty during mitral valve repair to facilitate dynamic annular motion while preventing annular dilation. In this study, we assessed the extent and nature of the flexibility of these rings in vivo, which has not been objectively demonstrated. METHODS: Three-dimensional transesophageal echocardiography was used intraoperatively to acquire data regarding dynamic motion of mitral annuli and annuloplasty rings in 33 patients undergoing mitral repair (15 CG Future and 18 CE Physio II) and in 15 control patients. Data were analyzed to assess the dynamic changes in annular geometry after implantation of selectively flexible rings. RESULTS: After annuloplasty, there was an immediate and significant decrease in annular displacement (p 0.001) and annular displacement velocity (p 0.01). Dynamic change in multiple variables including anteroposterior diameter (p 0.001) and annular area (p 0.001) was also significantly depressed. In comparison with normal mitral valves, partially flexible rings allowed limited dynamic motion: percentage changes in anteroposterior diameter (p 0.001), anterolateral posteromedial diameter (p 0.001), and total circumference (p 0.001) were significantly lower. Compared with each other, the two rings resulted in similar changes in anterior annulus length (p = 0.93), posterior annular length (p = 0.82), and annular area (p = 0.31). CONCLUSIONS: Mitral annular dynamics were uniformly depressed after implantation of these rings. Selective flexibility could not be demonstrated in vivo using echocardiographic data.

OBJECTIVE: To compare the determination of stroke volume (SV) and cardiac output (CO) using 2-dimensional (2D) versus 3-dimensional (3D) transesophageal echocardiography (TEE). DESIGN: Prospective observational study. SETTING: Tertiary care university hospital. PARTICIPANTS: 35 patients without structural valve abnormalities undergoing isolated coronary artery bypass grafting. INTERVENTIONS: Left ventricular outflow tract (LVOT) diameter determined with 2D TEE was used to estimate LVOT cross-sectional area (CSALVOT). LVOT area was measured directly with 3D TEE by planimetry on an en face view. SV and CO were calculated for both methods using the continuity equation. MEASUREMENTS AND MAIN RESULTS: The area of the LVOT differed significantly between methods, being significantly larger in the 3D method (3.57±0.70 cm(2)v 3.98±0.93 cm(2)) . This resulted in a 10% lower CO with the 2D method of LVOT area estimation. CONCLUSIONS: LVOT area is underestimated with the single- axis 2D method when compared with 3D planimetered area. This results in a CO that is approximately 10% lower with the 2D method.

BACKGROUND: Chronic hyperglycemia has been associated with increased oxidative stress in skeletal muscle and sympathetic nerve dysfunction. We investigated the effect of chronic hyperglycemia on the myocardium of patients with uncontrolled diabetes (UD) compared with patients with well-controlled diabetes (CD) and patients without diabetes (ND) after cardioplegic cardiopulmonary bypass (CP/CPB) with acute intraoperative glycemic control. METHODS: Atrial tissue and serum were collected from 47 patients (ND=18 with glycated hemoglobin [HbA1c] of 5.8±0.2; CD=8 with HbA1c of 6.1±0.1; with UD=21 with HbA1c=9.6±0.5) before and after CP/CPB for immunoblotting, protein oxidation assays, immunohistochemical evaluation, and microarray analysis. RESULTS: The uncontrolled group had increased total protein oxidation (p0.05) and decreased levels of antioxidative enzyme manganese superoxide dismutase (MnSOD) (p0.05) after CP/CPB compared with the controlled group. Collagen staining revealed increased fibrosis in patients with UD (p0.05) compared with patients with CD and patients without diabetes. The uncontrolled group also showed a decrease in the neurogenic and angiogenic markers nerve growth factor (NGF) (p0.05), neurotrophin (NT)-3 (p0.05), and platelet-derived growth factor (PDGF)-β (p0.05) compared with the other groups after CP/CPB. Atrial and serum microarray analysis showed increased oxidative stress and sympathetic nerve damage, increased fibrosis, and a decrease in angiogenesis in patients with UD (p0.03) compared with patients without diabetes. CONCLUSIONS: CP/CPB led to higher oxidative stress in patients with UD before surgical intervention, even after normal glucose levels were maintained intraoperatively. Thus, controlled HbA1C in addition to acute intraoperative glucose control may be a more suitable end point for patients with diabetes undergoing cardiac operations.