Echo-A Workshop Instructor’s Guidelines v7, March 2019

Purpose of Instructors’ Guidelines:

1. -to standardize the teaching approach so that the beginner participants can
follow easily in different stations with different instructors

2. -to facilitate instructors to teach by listing the core skills and knowledge
needed to be covered in the practical sessions

General points:

1. One 3D heart model per station will be provided to facilitate teaching

2. please arrive earlier at 0820 to familiarize the environment, model and

echo machines

3. always wear glove to avoid direct skin contact between participants and
models

4. perform study on patient left side with instructor’s left hand holding the
probe

5. position for parasternal and apical views is left lateral with left arm over
head; position for subcostal is supine with both knees bent upwards
to relax the abdominal muscles

6. please ensure all participants have equal hands-on time, each station will
have 3 participants

7. try to engage all the participants by asking them taking turns in each
window, rather than allowing one to complete getting all the
windows and the other two just watching and waiting

8. the workshop coordinator assess the overall progress of practical session

and co-ordinate station rotation in appropriate times

9. participants are encouraged to practice the windows on all the models and
make use tea break and lunch break if they cannot do it during the
practical sessions

10. sonographers will help faculty in the morning session for technical
assistance and view acquisition pearls

11. the models in the morning session will be different from models in
afternoon session to increase practice opportunities on live models
 Time Program
0815-0830 Registration
0830-0845 Demo 1*: Basic views in focused Echocardiography (FTE)
0845-0945 Practice 1#: Basic views (60min) on human models
Station 1 Station 2 Station 3 Station 4
A B C D
0945-1000 Demo 2: Echo assessment of ventricular function and fluid status
Measurements: LVDID, FS, TAPSE, IVC diameter
1000-1050 Practice 2: Basic views +hemodynamic assessment (50min)
Station 1 Station 2 Station 3 Station 4 Simulator
A B C D
1050-1100 Tea Break
1100-1145 Practice 3: Basic views +hemodynamic assessment (45min)
Station 1 Station 2 Station 3 Station 4 Simulator
D A B C
1145-1220 Practice 4: Basic views +hemodynamic assessment (40min)
Station 1 Station 2 Station 3 Station 4 Simulator
C D A B
1220-1300 Practice 5: Basic views +hemodynamic assessment (40min)
Station 1 Station 2 Station 3 Station 4 Simulator
B C D A
1300-1400 Lunch
1400-1415 Demo 3: Valve assessment by FTE
1415-1445 Practice 6: Basic views +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
A B C D
1445-1515 Practice 7: Basic views +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
D A B C
1515-1525 Tea Break
1525-1540 Demo 4: Practical skills assessment format and requirements
1540-1610 Practice 8: Basic views +hemodynamics +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
C D A B
1610-1640 Practice 9: Basic views +hemodynamics +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
B C D A
1640-1720 Practical skills assessment (Gp A,B)+ MCQ assessment(Gp C,D)
1720-1750 Practical skills assessment (Gp C,D)+ MCQ assessment(Gp A,B)
1750-1800 Course evaluation & Certificate Award
*Heartwork simulator needed to be ready at 0815, needs company rep. to support

#Human models needed to arrive at 0815(am session) and 1400(pm session)

Time Program (for instructors information only)
0815-0830 Registration (check all have accessed the e-learning course)
0830-0845 Demo 1*: Basic views in focused Echocardiography (FTE) Use ‘normal’
Demonstrate 4 probe movements module in
Illustrate the image requirements in the basic views Heartworks
0845-0945 Practice 1#: Basic views (60min) on human models
Station 1 Station 2 Station 3 Station 4
A B C D
0945-1000 Demo 2: Echo assessment of ventricular function and fluid status Use
Measurements: LVDID, FS, TAPSE, IVC diameter ‘hypovolemia’
module
1000-1050 Practice 2: Basic views +hemodynamic assessment (50min) On human
Station 1 Station 2 Station 3 Station 4 Simulator models and
A B C D simulator
1050-1100 Tea Break (global dysfx,
1100-1145 Practice 3: Basic views +hemodynamic assessment (45min) pulmonary
Station 1 Station 2 Station 3 Station 4 Simulator embolism,
D A B C tamponade
1145-1220 Practice 4: Basic views +hemodynamic assessment (40min) +/- RV
Station 1 Station 2 Station 3 Station 4 Simulator dysfunction
C D A B and TR)
1220-1300 Practice 5: Basic views +hemodynamic assessment (40min)
Station 1 Station 2 Station 3 Station 4 Simulator
B C D A
1300-1400 Lunch
1400-1415 Demo 3: Valve assessment by FTE Use ‘aortic
Demonstrate effects of low and high aliasing velocity stenosis’
Demonstrate the difference of CFD patterns in turbulent module
flow(aortic) and high velocity flow (pulmonary artery)
1415-1445 Practice 6: Basic views +valve assessment (30min) On human
Station 1 Station 2 Station 3 Station 4 Simulator models and
A B C D simulator
1445-1515 Practice 7: Basic views +valve assessment (30min) (AR, MS, MR
Station 1 Station 2 Station 3 Station 4 Simulator +/- RV
D A B C dysfunction
1515-1525 Tea Break and TR)
1525-1540 Demo 4: Practical skills assessment format and requirements
Use ‘RV dysfunction and TR’ module
Distribute the practical assessment forms to participants
1540-1610 Practice 8: Basic views +hemodynamics +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
C D A B
1610-1640 Practice 9: Basic views +hemodynamics +valve assessment (30min)
Station 1 Station 2 Station 3 Station 4 Simulator
B C D A
1640-1720 Practical skills assessment (Gp A,B)+ MCQ assessment(Gp C,D) 80% pass
1720-1750 Practical skills assessment (Gp C,D)+ MCQ assessment(Gp A,B) mark
1750-1800 Course evaluation & Certificate Award
 The use of Heartworks simulator

1 The use of simulator can help the participants to have immediate 3-D
feedbacks of probe placement and movement, especially with 3D image
of heart, ribs, sternum and the probe
2 Demo 1-4: We demo the basic views, probe movements, hemodynamic
measurements, valvular assessment, practical assessment format &
requirements
2.1 Demo 1: we demonstrate 4 probe movements which include
sliding/translation, rotation, tilting, and heel-toe
2.2 Demo 1: basic views include parasternal long axis (also
demonstrate tilting to show tricuspid valve and pulmonary valve),
parasternal short (LV and aortic valve level); apical 4 chamber (also
demonstrate 5 chamber view); subcostal 4 chamber and IVC view
2.3 Demo 1: demonstrate the structures required in the views and
criteria of the good views
2.4 Demo 2: shows how to properly take the measurements in 2D or M-
mode which include LVDID, FS, TAPSE, IVC diameter
 2.5 Demo 3: shows how to assess the aortic, mitral, tricuspid and
pulmonary valves in 2D and CFD in focused echo views
2.6 Demo 4: shows the standard requirements in the practice skills
assessment with reference to scoring sheet in the last page of this
guide
3 The simulator can simulate different pathological hemodynamic
emergencies and valvular pathologies and we can use it to illustrate the
focused echo approach to shock patient and patient with murmur
4 Simulator practice stations (morning): Focused echo approach to shock
patient
-we simulate 3 different hemodynamic conditions: global dysfunction,
pulmonary embolism, cardiac tamponade
-we brief the participants that the patient is hypotensive (SBP 60mmHg)
and ask the participant to use the focused echo to identify the cause of
shock and decide the appropriate management
-they need to use standard focused views to assess the LV, RV, volume
and pericardial status
5 Simulator practice stations (afternoon): focused echo approach to patient
with heart murmur
-we simulate 3 different valvular conditions for the 3 participants to
assess: AR with vegetation, MS with hockey stick and immobile
posterior mitral leaflet, MR with mitral valve prolapsed with eccentric
jet
-we use focused views (parasternal long axis, short axis at aortic and
mitral valve, 4 chamber view, 5 chamber view to assess the aortic,
mitral and tricuspid vlaves)
-we use 2D and CFD (aliasing velocity 50-60cm/s) to assess the
following
-a. appearance of the valves
-b. movement of the valves
-c. flow across the valves
-d. hemodynamic impact of the valvular lesions on LV & RV functions
6 Simulator for assessment: those who fail the practical skills assessment
(human model) can retake the assessment on Heartworks simulator in
order to minimize the effects of poor patient windows and to provide
accurate assessment & feedbacks for the participants to improve future
performance
Practice session: Basic views and Knobology (60min for 3 participants)
Knobology and probe manipulation
1. -explain the function of depth, gain, dynamic range, focus & TGC and
demonstrate their use to optimize the image. Show freeze and scroll
buttons of the echo machine

2. -explain the relationship of image index maker on the transducer probe

and marker on the screen

3. -explain 4 transducer maneuvers including movement(sliding), tilting,

angulation (heel-toe or panning) and rotation

Basic windows and views (4 windows and 6 views)

1. -we adopt the FREE protocol by Dr Ferrada Paula and we use the
parasternal, apical and subcostal windows to perform focused TTE
assessment

2. -we aim to teach participants to obtain parasternal long axis (PLA);

parasternal short axis (PSA) at aortic valve level & papillary muscle
level; apical 4 chamber view (A4C); subcostal 4 chamber (SX) and
IVC view

Parasternal long axis view

1. -show required structures: RV, interventricular septum, LV cavity, LV
posterior wall, LA, mitral valve and aortic valve, +/- descending
aorta

2. –both aortic valve and mitral valve in the same view and both at the largest
dimensions

3. –LV wall at the level of mitral valve leaflet tips clearly seen

4. –demonstrate inferior tilting to obtain the RV inflow long axis view

Parasternal short axis view (mid LV level)

1. -show required structures: donut shaped LV, interventricular septum, RV,
papillary muscles

2. both papillary muscle head similar size

3. to differentiate the papillary muscles from chordae tendinae

4. -explain anterior, inferior, septal and lateral walls of LV

5. -demonstrate tilting of transducer to obtain views of aortic valve and
mitral valve

Parasternal short axis view (aortic valve level)

1. show required structures: aortic valve appears circular with 3 cusps in the
centre, tricuspid valve on the left, RVOT and pulmonary valve on the right,
interatrial septum

Apical 4 chamber view

1. -show required structures: LA, LV, mitral valve, RA, RV, tricuspid valve,
descending aorta

2. -LV at its longest dimension with both LA and RA at largest dimensions;

heart appearing olive shape

3. -demonstrate fore-shortening

4. -demonstrate normal relative size of LV and RV

5. -panning medially to obtain RV focused 4 chamber view

6. -demonstrate tilting of transducer to obtain apical 5 chamber view

7. +/- show coronary sinus by tilting the transducer inferiorly

Subcostal 4 chamber view & IVC view

1. show required structures in 4 chamber view: LA, LV, mitral valve, RA,
RV, tricuspid valve, liver

2. show anticlockwise rotation of probe to visualize IVC entry into RA, at

least 1-2cm of IVC (from the RA/IVC junction) needed to be seen

3. –IVC at largest dimension with respiratory variation

4. demonstrate sniff test to demonstrate IVC collapse

5. demonstrate tilting of transducer to identity the aorta

Standard Transthoracic Echocardiography(TTE) views
parasternal long axis (PLA), parasternal short axis (SA), and
apical four-chamber and subxiphoid (SX) windows

TTE probe positions. (1) Parasternal long view and parasternal short. (2) Apical four-
chamber view. (3) Subcostal (SX) view.

A) Parasternal long view. (B) Parasternal short view. (C) Apical four-chamber
view. (D) subcostal view.
Parasternal Windows (long axis, PLA & short axis, SA)
Right side up with left head above head. Supine if patient cannot lie lateral.
The first two views are taken in between the second and sixth intercostal
space and are the PLA and the parasternal SA. The PLA is obtained with the
transducer notch facing the right shoulder. In this position, the mitral and
aortic valves can be imaged, as well as left ventricular function. In
parasternal SA, the echo probe is now rotated 90 degrees. In this position,
the classic “donut view” of the left ventricle is seen along with the right
ventricle. Tilting the probe allows imaging of the left ventricle from the base
to the apex. In each position, important aspects and cardiac structures can be
seen, including papillary muscles and mitral and aortic valves.
Apical Window
The probe is next placed along the left chest wall at the cardiac apex in the
apical window to obtain an apical four-chamber view. The transducer notch
is turned to the bed. This view allows for visualization of left and right
ventricular functions, as well as determination of blood flow through valves
by Doppler.

MB=moderator band, LV=Left ventricle, RV=Right ventricle, LA=Left atrium,

RA=Right atrium, RSPV=Right superior pulmonary vein, DA=Descending
thoracic aorta
Subcostal (SX)Window

The SX view is obtained by placing the probe under the xiphoid process.
This view allows for the visualization of the IVC and for evaluation of
pericardial effusions. Rotation of the probe counter anti-clockwise opens the
IVC in long axis. Once the IVC is visualized, M mode is used to better
determine IVC diameter and collapsibility. (In mechanically ventilated
patients, IVC diameter is maximal at inspiration and minimal on expiration.
Subcostal view, with M mode demonstrating collapsibility of the IVC
Practical session: Basic views + Hemodynamic assessment &
measurement
1. continue basic view acquisition practice with emphasis on how to evaluate
the LV, RV function and pericardial and fluid status

2. introduce knobology for 2D and M-mode measurement

3. teach and perform simple relevant hemodynamic 2D measurement and M-

mode measurement (tips for accurate M-mode measurement)

View Measurement Normal values

LVIDD (at mitral leaflet tip level at
PLA diastole) -by 2D measurement, inner edge 3.0-5.6cm
to inner edge dimension of LV
Fractional shortening (FS)
-by 2D or M-mode -inner edge to inner
edge
PSA -to measure systolic internal diameter 28-44%
(LVSD) and diastolic diameter (LVDD)
of LV
- FS = (LVDD-LVSD)/LVDD
Tricuspid annular plane systolic excursion
A4C (TAPSE) -by M-mode or 2D in focused >=1.5cm
RV A4C view
IVC diameter & respiratory variation -by
SX M-mode or 2D 1.6 +/- 0.3

Practical session: Basic views +Valvular assessment

1. continue basic view acquisition with focus on valve assessment: aortic
valve (PLX, PSA, apical 5), mitral valve (PLA, PSX, apical 4,
subcostal), tricuspid (PSA, apical 4)

2. introduce knobology of CFD (position, size) and importance of aliasing

velocity 50-60cm/s
Practical skills assessment
-15min for each participant
-select a model with normal echo windows for assessment
-participants need to demonstrate correctly how to obtain the following FTE
views and perform measurement
-participant can look at this form to minimize stress during assessment
Views Structures & measurements Marks Score
Parasternal RV, interventricular septum, LV cavity, LV 3
long axis posterior wall, LA, mitral valve and aortic
valve, +/- descending aorta

Measure LV diastolic internal diameter at level 1

of tip of mitral valve leaflets (2D or M-mode)
CFD assessment aortic and mitral valve 2
Parasternal aortic valve with 3 cusps in the centre, tricuspid 3
short axis valve on the left, RVOT and pulmonary valve on
(aortic valve) the right, interatrial septum
CFD assessment of tricuspid valve 1
CFD assessment of pulmonary valve 1(bonus)
Parasternal donut shaped LV, interventricular septum, RV, 3
short axis (mid papillary muscles
LV)
Measure systolic and diastolic internal 2
diameters and calculate fractional shortening
(2D or M-mode)
Apical 4 LA, LV, mitral valve, RA, RV, tricuspid valve, 3
chamber descending aorta

Measure TAPSE (2D or M-mode) 1

CFD mitral and tricuspid valves 2
CFD aortic valve 1(bonus)
Subcostal 4- LA, LV, mitral valve, RA, RV, tricuspid valve, 3
chamber liver

Subcostal IVC IVC, RA 3

Measure IVC diameter 1 cm from RA-IVC 1
junction (2D or M-mode)
CFD of IVC and aorta 2
Participant name: Max mark Total
30 score:
Assessor name: Pass mark
Date of assessment: 24 (80%)
Pass/ Fail