Simulation-Based Transesophageal Echocardiography Training Improves Skills of Cardiology Fellows

Simulation-based teaching of transesophageal echocardiography was found to be beneficial among cardiology fellows.

Knowledge, aptitude, and self-assessment of proficiency was found to improve with simulation-based training in transesophageal echocardiography (TEE) among cardiology fellows, according to study findings published in the Journal of the American Medical Association Cardiology.

Researchers sought to evaluate the effectiveness of simulation-based teaching vs traditional teaching of TEE in improving the knowledge and skills of cardiology fellows.

Researchers conducted a multicenter, parallel-group, randomized study (SIMULATOR; Identifier: NCT05564507) that enrolled consecutive cardiology fellows (year 1-4) from 42 centers in France between November 2020 and 2021.

The primary study endpoints were the differences in scores in the final practical and theoretical tests 3 months after training.

Self-assessment of proficiency and TEE duration were also evaluated.

These results also highlight the difference between improving TEE skills and becoming autonomous in performing a TEE alone.

Of a total of 375 cardiology fellows, 324 (62.6% women; mean age, 26.4 years) were randomly assigned 1:1 into the simulation group (n=162) or the traditional group (n=162). Researchers noted that 20% of all participants had previously observed more than 20 TEEs.

Researchers found baseline test scores before training were similar between the 2 groups. Higher theoretical and practical test scores were achieved in the simulation vs traditional group after the training (47.2% [SD, 15.6%] vs 38.3% [SD, 19.8%]; P <.001) and (74.5% [SD, 17.7%] vs 59.0% [SD, 25.1%]; P <.001), respectively.

The 2 groups were comparable in TEE duration before training. However, the duration to perform a complete TEE was significantly lower in the simulation vs traditional group after training (8.3 [SD, 1.4] vs 9.4 [SD, 1.2] minutes; P <.001). .

Self-confidence in performing a TEE after training was higher in the simulation vs traditional group (mean score, 3.3; 95% CI, 3.1-3.5 vs 2.4; 95% CI, 2.1-2.6; P <.001).

Effectiveness of the simulation training was greater among fellows with 2 years or less of training vs those with more than 2 years of training (theoretical test: increase of 11.9 points; [95% CI, 7.2-16.7 points] vs increase of 4.25 points; [95% CI, -1.05 to 9.5 points]; P =.03; practical test: increase of 24.9 points; [95% CI, 18.5-31.0 points] vs increase of 10.1 points; [95% CI, 3.9-16.0 points]; P =.001).

Study limitations included that cardiology fellows in the simulation group may have manipulated the TEE probe during training sessions; the traditional group may have received more online training than the simulation group; and the lack of data on the number of TEEs performed by the fellows in both groups during the study period.

Researchers acknowledged the 2-hour training sessions were not sufficient to achieve expert level in TEE and the final results of the simulation group were moderate (47 of 100 points in theoretical and 74 of 100 points in practical).

They added, “These results also highlight the difference between improving TEE skills and becoming autonomous in performing a TEE alone.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Pezel T, Dreyfus J, Mouhat B, et al; for the SIMULATOR investigators. Effectiveness of simulation-based training on transesophageal echocardiography learning the SIMULATOR randomized clinical trial. JAMA Cardiol. Published online January 11, 2023.  doi:10.1001/jamacardio.2022.5016