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EACVI collaborates with Surgical Science to pilot the first online Transesophageal Echo (TOE/TEE) testing

The EACVI (European Association of Cardiovascular Imaging) and Surgical Science have joined forces to create a unique Transesophageal Echo online simulator. This collaboration aims to evaluate TOE knowledge and performance level among young cardiologists and assess the need for simulation for this purpose.

Over 716 cardiologists from 81 countries have been tested online. A newly published study revealed that there is a TOE skill deficiency among young cardiologists and that higher test results were independently associated with prior simulation training, prior clinical experience and EACVI certification.


Transesophageal echocardiography (TOE) is an important cardiovascular imaging modality that allows main sections of the heart and great vessels to be clearly demonstrated from the esophagus. This procedure is safe when properly conducted, but can cause complications, even in the hands of experienced practitioners. Therefore, establishing basic competencies in a controlled, simulation setting is an opportunity to reduce procedural risk. (1) Cardiology fellows need to conduct at least 50 supervised TOE studies in order to be certified as having the required skills to perform TOE independently and are encouraged to spend an additional three months of dedicated training in echocardiography (2).

Simulation allows cardiology fellows to practice TOE from the beginning of their training, prior to performing this exam on an actual patient. A research has shown that Simbionix Ultrasound Mentor simulator for TOE training is effective and may reduce the number of real patient TOEs required for training purposes (3).

Cloud Simulation

The COVID-19 pandemic has required medical educators around the globe to adapt their teaching approach from in-person to remote. This necessity led the Surgical Science team to initiate one of the pioneering projects of ultrasound cloud-based simulation, in which trainees are able to navigate a virtual TOE probe to capture standard views and train remotely over the cloud from anywhere at any time.

In collaboration with the EACVI Heart Imagers of Tomorrow (HIT) committee, an assessment for TOE skills and knowledge was developed, in which the trainee follows the scan protocol to capture 10 standard views and identify anatomical structures in each.

The cloud-based simulation can assist in learning the anatomy and the probe manoeuvring required to achieve the desired echocardiographic standard views.


Online TOE Simulator Study

716 young cardiologists from 81 countries participated in the study.

After a short survey, each participant completed two tests: a theoretical test to assess TOE knowledge and a practical test using an online TOE simulator to investigate TOE skills.

The study concluded that online evaluation of young cardiologists around the world showed a relatively low level of TOE skills and knowledge. Prior participation in a TOE simulation-based training session, a higher number of TOE exams performed per week, and the EACVI certification for TOE were independently associated with a higher global score.

These findings emphasize the important impact of EACVI certification regarding TOE knowledge and skills for all young cardiologists.

Dr. Theo Pezel, French ambassador of HIT EACVI: “This collaboration between the EACVI and Simbionix was a pioneering pilot in remote training and assessment of TOE knowledge and skill. Based on the largest international online study assessing theoretical knowledge and practical skills in TOE among young cardiologists around the world, we emphasized a relatively low level of TOE skills and knowledge, with a growing need for simulation-based training."

In accordance with the EACVI recommendations for training, competence, and quality improvement in echocardiography (3) simulation-based training programs are the present and the future of TOE teaching. The relevance and implementation of this kind of program is currently being tested by the ongoing randomized SIMULATOR study (4).

Surgical Science continues to invest in developing new simulation technologies, including cloud-based simulation, in order to enable training in distant locations to a wide audience with no limits.


  3. Criteria for surveys: from the European Association of Cardiovascular Imaging Scientific Initiatives Committee | European Heart Journal - Cardiovascular Imaging | Oxford Academic (