User Manual - Inventive Medical

HeartWorks User Manual
HeartWorks 1.1
© Inventive Medical Ltd
HeartWorks
Inventive Medical Ltd.
th
5 Floor East
250 Euston Road
London NW1 2PG
Tel: (+44) 207 3809360
www.heartworks.me.uk
Contents
Contents ............................................................................................................. 1
1 Introduction ................................................................................................... 5
1.1 Background .............................................................................................. 5
1.2 Credits...................................................................................................... 6
2 Disclaimer ...................................................................................................... 7
3 Packages ....................................................................................................... 8
3.1
3.2
3.3
3.4
3.5
3.6
Anatomy Package .................................................................................... 8
TEE Simulation Package ......................................................................... 8
TTE Simulation Package ......................................................................... 9
TTE and TEE Simulation Package .......................................................... 9
TEE Manikin Simulator Package ........................................................... 10
TTE and TEE Manikin Simulator Package ............................................ 10
4 Hardware.......................................................................................................11
4.1 Computer ................................................................................................11
4.2 TEE Manikin ...........................................................................................11
4.3 TTE Manikin ............................................................................................11
4.4 Setup...................................................................................................... 12
4.4.1 Equipment ....................................................................................... 12
4.4.2 Installing your new HeartWorks simulator ...................................... 14
4.4.3 Magnetic Interface Warning ............................................................ 15
4.4.4 TTE and TEE + TTE specific setup ................................................ 17
5 The launch panel ........................................................................................ 19
5.1 The legal disclaimer ............................................................................... 19
5.2 The launch panel ................................................................................... 19
5.2.1 Choosing a screen resolution ......................................................... 19
5.2.2 Starting the software ....................................................................... 20
5.2.3 Shutting down the system............................................................... 20
5.2.4 Accessing the administrative tools panel ........................................ 20
6 Getting help ................................................................................................. 21
6.1 Documentation ....................................................................................... 21
6.2 Tool-tips.................................................................................................. 21
7 The user-interface ....................................................................................... 22
7.1 Basic controls and terminology .............................................................. 22
7.1.1 The mouse ...................................................................................... 22
7.1.2 Common GUI components ............................................................. 23
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7.2 Panels .................................................................................................... 24
7.2.1 Resizing panels .............................................................................. 25
7.2.2 Swapping the panel content ........................................................... 25
7.2.3 Changing the panel layout .............................................................. 26
7.2.3.1 Horizontal split button .............................................................. 27
7.2.3.2 Vertical split button ................................................................... 27
7.2.3.3 Vertical expand button ............................................................. 28
7.2.3.4 Close panel button ................................................................... 28
7.2.3.5 Expand button .......................................................................... 29
7.2.3.6 Collapse button ........................................................................ 29
7.2.4 Hiding and showing the toolbars..................................................... 29
8 The EKG and timeline ................................................................................. 30
8.1
8.2
8.3
8.4
8.5
8.6
Switching between the EKG and timeline.............................................. 30
Hiding and showing the timeline panel .................................................. 30
Starting and stopping playback ............................................................. 31
Jumping to a specific time ..................................................................... 31
Scrubbing the timeline ........................................................................... 31
Slowing down playback ......................................................................... 32
9 The 3D view ................................................................................................. 33
9.1 Navigating around the heart .................................................................. 33
9.1.1 The camera toolbar ......................................................................... 33
9.1.2 Manipulating the camera ................................................................ 33
9.1.2.1 Orbit ........................................................................................ 34
9.1.2.2 Dolly ........................................................................................ 35
9.1.2.3 Track ....................................................................................... 35
9.1.2.4 Pan .......................................................................................... 36
9.1.2.5 Roll .......................................................................................... 37
9.1.3 Constraining the camera to the ultrasound probe .......................... 37
9.2 Slicing .................................................................................................... 38
9.2.1 The slice toolbar ............................................................................. 38
9.2.2 Slice modes .................................................................................... 38
9.2.2.1 None ........................................................................................ 39
9.2.2.2 Camera slicing mode ............................................................... 39
9.2.2.3 Manipulator slicing mode ......................................................... 41
9.2.2.4 Ultrasound slicing mode .......................................................... 43
9.3 Intracardiac structure visibility................................................................ 44
10 The browser .............................................................................................. 45
10.1
10.2
10.3
10.4
Changing language and nomenclature ................................................ 45
Highlighting and selecting intracardiac structures ............................... 46
Default views ....................................................................................... 46
Intracardiac structure visibility.............................................................. 47
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10.5 The intracardiac structures page ......................................................... 47
10.5.1 Expanding and collapsing lists...................................................... 47
10.5.2 Showing and hiding multiple structures ........................................ 48
10.6 Getting information about a structure .................................................. 48
10.6.1 Echocardiography Imaging planes ............................................... 49
11 Ultrasound simulation .............................................................................. 50
11.1 The ultrasound view ............................................................................. 50
11.1.1 Structure visibility .......................................................................... 50
11.1.2 Inverting the ultrasound image...................................................... 51
11.1.3 Setting the initial orientation .......................................................... 51
11.1.4 Depth-of-field................................................................................. 51
11.2 The ultrasound control panel ............................................................... 52
11.2.1 Opening and closing the control panel ..................................... 52
11.2.2 Selecting the ultrasound simulation mode ................................ 52
11.3 TEE simulation ..................................................................................... 53
11.3.1 The simulated TEE probe ............................................................. 54
11.3.2 The TEE tab .................................................................................. 55
11.3.3 Moving the probe........................................................................... 55
11.3.4 The TEE manikin........................................................................... 57
11.3.4.1 Enabling and disabling ........................................................... 57
11.3.4.2 Simulated probe controls ....................................................... 58
11.3.5 Standard imaging planes .............................................................. 58
11.4 TTE simulation ..................................................................................... 58
11.4.1 Additional organs .......................................................................... 59
11.4.2 The simulated TTE probe ............................................................. 61
11.4.3 The TTE tab .................................................................................. 62
11.4.3.1 Enabling and disabling ........................................................... 62
11.4.4 The TTE manikin ........................................................................... 63
11.4.4.1 Registered positions .............................................................. 64
11.4.5 Standard imaging planes .............................................................. 64
12 Structures .................................................................................................. 65
12.1 Highlighting and selecting intracardiac structures ............................... 65
12.1.1 Selection mode ............................................................................. 65
12.1.2 Highlighting ................................................................................... 66
12.1.3 Selection ....................................................................................... 66
12.1.4 Overlapping structures .................................................................. 67
12.2 Intracardiac structure visibility.............................................................. 67
12.3 Default views ....................................................................................... 68
12.4 The slide toolbar .................................................................................. 68
12.5 Slide pages .......................................................................................... 69
12.5.1 Creating slide pages ..................................................................... 69
12.5.2 Deleting slide pages ..................................................................... 69
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12.5.3 Renaming slide pages .................................................................. 69
12.5.4 Locking slide pages ...................................................................... 70
12.6 Slides ................................................................................................... 70
12.6.1 Creating slides .............................................................................. 70
12.6.2 Showing slides .............................................................................. 70
12.6.3 Deleting slides .............................................................................. 71
12.6.4 Renaming slides ........................................................................... 71
12.6.5 Changing the order of slides ......................................................... 71
12.6.6 Setting the content of slides.......................................................... 72
12.6.7 Modifying the content of slides ..................................................... 72
12.7 Predefined slide pages ........................................................................ 73
12.7.1 Intracardiac structures .................................................................. 73
12.7.2 TEE standard imaging planes ...................................................... 73
12.7.3 TTE standard imaging planes ....................................................... 73
13 Screen capture .......................................................................................... 74
13.1 Preparing to take screenshots ............................................................. 74
13.2 Taking a screenshot ............................................................................. 74
13.3 Multiple screenshots ............................................................................ 75
13.4 Transferring screenshots ..................................................................... 76
13.5 How screenshots are named ............................................................... 76
13.5.1 No intracardiac structure selected ................................................ 76
13.5.2 With an intracardiac structure selected ........................................ 77
13.6 Troubleshooting screenshots ............................................................... 77
14 Appendix A - Shortcuts ............................................................................ 78
15 Appendix B - GUI ...................................................................................... 80
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1 Introduction
HeartWorks is a computer based teaching tool for cardiac anatomy,
transesophageal echocardiography (TEE) and transthoracic echocardiography
(TTE). It comprises a freely interactive 3D model of the heart, with optional TEE
and TTE simulation.
1.1 Background
HeartWorks was developed by three cardiac anesthesiologists at The Heart
Hospital (University College Hospital), London UK. The three clinicians who
have led the project direct a highly successful course in peri-operative
transesophageal echocardiography. They developed the idea of creating a
virtual heart in response to the surprising absence of a sufficiently accurate
model of the heart with which to teach cardiac anatomy to their students. The
idea of using the anatomical 3D data set to generate a simulated ultrasound
image was a natural progression from this point. A chance conversation with
friends led to contact with Glassworks Ltd, an award-winning computer graphics
company with a strong track record in taking on unusual projects. Painstaking
research and collation of large amounts of reference material, combined with
input from a wide range of clinicians and cardiac morphologists at the leading
edge in their fields has complemented the expertise of Glassworks to produce
an anatomical model of unsurpassed accuracy and realism. Custom designed
ultrasound simulation software by Glassworks and Existential Ltd has resulted
in freely interactive TEE and TTE image simulation with true to life control of the
probe. The system is complemented by a solid manikin TEE and TTE simulator
developed by Asylum Models and Effects, which allows students to learn the
practical skills of image acquisition away from the clinical setting.
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1.2 Credits
Project Directors
Dr. Bruce Martin
Dr. Andrew Smith
Dr. Sue Wright
Medical Specialist Advisors
Dr. Andrew Cook
Prof. Sir Magdi Yacoub
Prof. Robert Anderson
Prof. Philipp Bonhoeffer
Mr. Justin O’Leary
Miss Carin van Doorn
Dr. Malcolm Walker
Dr. Martin Lowe
Dr. Pier Lambiase
Dr. Andrew Taylor
Dr. Vivek Muthurangu
Dr. Gavin Wright
University College London Hospitals Charities
www.uclhcharity.org.uk
Inventive Medical Ltd
www.heartworks.me.uk
GlassWorks Ltd
www.glassworks.co.uk
Asylum Models and Effects
www.asylumsfx.com
Existential Ltd
www.existential.ltd.uk
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2 Disclaimer
1. HeartWorks is an echocardiography training aid for use as a part of
medical training. It must only be used for training purposes and
not for diagnostic or other purposes. HeartWorks features static
and animated anatomical representations that are generic in
nature and accordingly HeartWorks may not be completely realistic
and or fully accurate in every respect.
2. HeartWorks must be used at all times strictly in accordance with
the user manual supplied by IML.
3. Licenses for HeartWorks are strictly controlled. You may not copy,
modify, distribute or adapt HeartWorks in any way or install any
component of HeartWorks on another computer.
4. Individuals must not translate, decompile, reverse engineer or
disassemble HeartWorks or make any derivative works of
HeartWorks. Any attempt to do so will be an infringement of the
license from IML and may result in the authorized licensee's
license being terminated and legal action against the individual.
5. Individuals must not remove, alter or obscure this notice or any
product identification, logo, copyright or patent notice or trade mark.
6. All rights in HeartWorks are retained by IML and its licensees.
7. For the purposes of these terms and conditions HeartWorks
means any part of the software, manikins and other deliverables
(including manuals and documentation) supplied by IML to the
authorized licensee.
8. English law governs these terms and conditions and users submit
to the non-exclusive jurisdiction of the English courts.
7
3 Packages
3.1 Anatomy Package
At the core of the HeartWorks product is a freely interactive computer generated
model of the human heart which has an unprecedented degree of anatomical
detail. It has a realistic appearance and has been carefully animated to simulate
normal human cardiac motion. The heart rate is synchronized to an EKG trace
and the beating heart is freely controlled by the computer keyboard and mouse
controls; it can be viewed from any angle both internally and externally, sliced in
any plane and examined in slow motion.
Incorporated into the system is a comprehensive manual of cardiac anatomy.
Over 160 separate intracardiac structures have been labeled, with
accompanying detailed anatomical text. Any selected structure can be
simultaneously highlighted in the text and displayed within the 3D model. A
number of predefined areas of the heart can be displayed separately or in
combination, facilitating understanding of anatomical relationships.
The
arrangement of the display windows on the screen can be adjusted by the
operator to suit personal preference.
3.2 TEE Simulation Package
This addition to the core anatomical model introduces the facility for real-time
TEE image simulation. A virtual multiplane TEE probe can be inserted down the
path of the esophagus generating TEE ultrasound images that are derived
directly and continuously from the 3D heart model. The TEE probe position,
flexion, rotation and angulation are controlled by keyboard and mouse using
familiar on-screen controls.
The 3D model can be set to display the 'cut surface' at the level of the TEE
ultrasound plane to further clarify the plane orientation. This mode allows clear
visualization of the relationship between the 2D TEE image and the underlying
3D anatomy of the heart.
8
Selection of a labeled structure in the 3D model is accompanied by highlighting
of that structure in the simulated TEE image and vice versa, so that the user
can easily identify any intracardiac region.
The TEE Simulation Package can be supplemented by a TEE
manikin simulator. See section 3.6 TEE Manikin Simulator
Package for details.
3.3 TTE Simulation Package
Similar to the TEE Simulation Package this package adds the facility for real
time TTE image simulation to the core anatomical model. The introduction of a
virtual TTE probe along with additional soft and bony structures allows TTE
ultrasound images to be derived directly and continuously from the 3D model.
The package includes a TTE manikin that consists of a life-size, upper-body
torso with realistic TTE probe. The manikin allows the virtual TTE probe to be
manipulated in a familiar and authentic fashion.
The 3D model can be set to display the 'cut surface' at the level of the TTE
ultrasound plane to further clarify the plane orientation. This mode allows clear
visualization of the relationship between the 2D TTE image represented on the
screen and the underlying 3D anatomy of the heart and surrounding structures.
Selection of a labeled structure in the 3D model will be accompanied by
highlighting of that structure in the simulated TTE image and vice versa, so that
the user can easily identify any intracardiac region.
3.4 TTE and TEE Simulation Package
The TTE and TEE Simulation Package combines all the functionality of the
Anatomy Package, the TEE Simulation Package and the TTE Simulation
Package in a single simulator system.
9
The user can switch instantly between TEE and TTE simulation at the touch of a
button.
The TTE and TEE Simulation Package can be supplemented by a
TEE manikin simulator. See section 3.6 TTE and TEE Manikin
Simulator Package for details.
A robust case which allows easy storage and transport of the TTE
manikin is available.
3.5 TEE Manikin Simulator Package
The TEE manikin simulator supplements both the TEE Simulation Package and
the TTE and TEE Simulation Package. With easy USB connection to any TEE
system, the physical probe controls the position of the simulated TEE probe
allowing the operator to perform true-to-life TEE examinations using a life-size,
upper-body torso and realistic TEE probe with authentic controls.
A robust case which allows easy storage and transport of the TEE
manikin is available.
3.6 TTE and TEE Manikin Simulator Package
The TTE and TEE manikin simulator package supplements both the TEE
Simulation Package and the TTE and TEE Simulation Package. With easy USB
connection to a TTE and TEE system, the physical probes control the position
of the simulated TTE or TEE probe, allowing the operator to perform true-to-life
TTE and TEE examinations using a life-size, upper-body torso and realistic TTE
and TEE probe with authentic controls.
A robust case which allows easy storage and transport of the
manikin is available.
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4 Hardware
4.1 Computer
Dell workstation
o T3400 Intel Core 2 Duo Processor E4800 (3.00GHz, 6MB) (Dual-Core)
o 2048 (2x1024) 800MHz DDR2 Dual Channel ECC
o Nvidia Quadro FX 4800 DDR3 graphics card
o 80GB (10,000Rpm) Serial ATA hard drive
o Windows Vista Business Edition SP1 with XP Media
Dell Standard Quietkey USB Keyboard Black (QWERTY)
Dell 2 Button USB Scroll Optical Mouse Black
Dell 24” 2408WFP Widescreen Ultrasharp Black (1920x1200)
DVI cable & VGA cables
2 power cables
4.2 TEE Manikin
TEE Manikin Simulator Package only (see section 3.5).
Torso
TEE Probe
USB cable
The torso and simulator ultrasound probe can be cleaned when
necessary using a damp cloth. No solvents should be used on the
unit.
4.3 TTE Manikin
TTE simulation packages only (see section 3.3).
Torso
TTE Probe
11
4.4 Setup
4.4.1 Equipment
1 x Life Sized Torso (with soft area insert) manikin.
1 x Dell Desktop Computer & 1 x 24” Dell Monitor.
1 x Simulator TEE Probe (TEE, TEE+TTE versions only)
1 x Simulator TTE Probe (TTE, TEE+TTE versions only)
12
Equipment (Continued…)
1 x Scroll Wheel Mouse
1 x Keyboard
1 x HeartWorks USB Stick & HeartWorks Mouse Mat
1 x DVI Cable
1 x DVI to Display Port adaptor
2 x Power Cable
13
4.4.2 Installing your new HeartWorks simulator
1.
Get to know the support materials that came with your simulator.
2.
Unpack all equipment carefully and check it against the list.
3.
Connect Mouse and Keyboard via the rear USB cables at the back of the
desktop computer.
4.
Connect the DVI cable to the monitor. Connect the other end of the DVI
cable to the DVI to Display Port adaptor, and insert the Display Port plug
into one of the sockets at the back of the desktop computer. Plug the
power cable into the monitor. Switch on the power button on the back of
the monitor.
14
4.4.3 Magnetic Interference Warning
HeartWorks uses a highly accurate, pulsed direct current magnetic field tracking
system. However, the presence of large metal objects or strong magnetic fields
near the HeartWorks manikin can affect the tracking performance.
Do not mount the manikin on any kind of metal table, trolley, box or filing cabinet.
Avoid tables with large metal support structures.
Keep all electricity supply cables away from the manikin.
Keep the manikin and simulator probes away from monitors, keyboards, mice,
mobile phones and other portable electronic equipment while operating the
HeartWorks system.
15
5. All connections from TEE and TTE probes are made at the front of the PC.
The CD-ROM drive is at the top, the 3D guidance panel immediately below
that and the secondary probe connection ports are below that.
3D guidance panel
Secondary probe
connections
6. Connect the white Transmitter cable from the manikin to the port marked
Transmitter on the front panel of the desktop. The cable inserts in only 1
position, so apply light pressure and rotate it until you feel it click into place.
When removing the plug, pull back out the outermost metal sleeve; do not
pull on the cabling.
16
4.4.4 TTE & TEE + TTE versions only
7. For the TTE Probe, connect the cable with the blue marker, to the port with
the blue indicator on the 3D Guidance panel. The cable inserts into only 1
position, so apply light pressure and rotate it until you feel it click into place.
When removing the plug, pull back out the outermost metal sleeve; do not
pull on the cabling.
Connect the cable with the yellow marker into the port with the yellow
marker on the secondary panel. Twist until the connection is secure.
17
TEE & TEE + TTE versions only (contd.)
8.
For the TEE Probe, connect the cable with the white marker, to the port
with the white indicator on the 3D Guidance panel. The cable inserts into
only 1 position, so apply light pressure and rotate it until you feel it clicks
into place. When removing the plug, pull back out the outermost metal
sleeve; do not pull on the cabling.
Connect the cable with the red indicator into the port with the red indicator
on the secondary panel. Twist until the connection is secure.
Ensure your power supply is turned on. Connect power cables from the
desktop to you power supply. Switch on the desktop computer.
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5 The Launch Panel
5.1 The Legal Disclaimer
9.
When the system starts it will prompt you to accept a legal disclaimer. You
must accept the legal disclaimer before using the software. Once you
accepted the legal disclaimer you will be presented with the launch panel.
5.2 The Launch Panel
10. Once the system has booted it will launch to the HeartWorks Launch Panel.
The Launch Panel can be used to perform various administrative tasks as
well as launching the main HeartWorks application.
5.2.1 Choosing a screen resolution
The Launch Panel allows you to specify the screen resolution whilst
using the HeartWorks application. When the ‘Use Default Resolution’
option is tagged the Preloader detects the maximum resolution
supported by the primary display device.
19
5.2.2 Starting the software
To start the software press the Launch HeartWorks button. Starting the
software will also hide the Preloader. To return to the Preloader from the main
HeartWorks application use the exit option under the help drop-down menu.
5.2.3 Shutting down the system
To shutdown the system from the Preloader press the Shutdown button. If
HeartWorks is still running, select the Help Menu and click Exit. Then choose
the Yes button. This will take you back to the Preloader where you can
shutdown as previously described.
5.2.4 Accessing the Administrative Tools Panel
To access the administrative tools panel press the Administrative tools button.
20
6 Getting help
6.1 Documentation
This document can be accessed within the software by clicking on the help
button in the top left corner of the screen. The documentation is displayed in
the browser (see section 10 The Browser).
6.2 Tool-tips
All controls within the software have associated tool-tips that briefly describe the
control’s function. To view the tool-tip for a particular control hold the cursor
stationary over the control for a short duration.
21
7 The user-interface
The user-interface is divided into a series of panels and toolbars. The panels
display interactive content whilst the toolbars provide a series of buttons and
menus that allow access to the software’s feature.
7.1 Basic controls and terminology
The software is controlled through a combination of mouse and keyboard
controls. The following section will be familiar to anyone with basic computer
skills.
7.1.1 The mouse
The mouse is the primary pointing device used to determine the position of the
on-screen cursor. The HeartWorks software requires the use of three mousebuttons commonly referred to as the left, middle and right mouse-buttons. In this
document the mouse-buttons will be referred to as follows:
Button
Abbreviation
Left mouse-button
LM B
Middle mouse-button
MMB
Right mouse-button
RM B
The middle-mouse button is also commonly referred to as the scroll-wheel since,
in addition to being pressed, it can also be rotated (or scrolled) up and down like
a dial.
The following terms will be used throughout this document to describe mouserelated actions:
Term
Description
Example
Hovering
To position the cursor over an
element without pressing any
buttons
Hover over the panel.
Holding
To hold a button in the pressed
state
Press and hold the LM B; hold
the L M B.
Dragging
To move the mouse whilst
holding a button
Hold the LM B and drag
left/right; drag the slider left.
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Clicking
To press and release a button
Click on the panel with the
LM B; left-click on the panel.
Selecting
The same as clicking (typically
when choosing amongst
several options)
Select option A from the list;
select the left panel.
Scrolling
To rotate the MM B
Scroll up/down whilst hovering
over the panel.
7.1.2 Common GUI components
GUI is a common abbreviation of Graphical-User-Interface. The GUI consists of
visual elements that allow the user to interact with the software in an intuitive
manner. The following is a list of components used within the software.
Component
Description
Panel
A rectangular area on the screen that typically displays
information and may also contain other GUI components.
Divider
Panels are separated by vertical and horizontal bars referred to
as dividers. Some panels may be resized by clicking and
dragging dividers with the LM B.
Toolbar
A rectangular bar that consists of a series of buttons and/or
drop-down menus. Some toolbars can be collapsed down to a
single button when not in use.
Button
An element that emulates the behavior of a real button in that it
can be pressed and released. Buttons are used by hovering
over them with the cursor and clicking with the LM B. Certain
buttons may perform different actions when pressed with the
middle or right mouse buttons or when a key is held down.
Drop-down
menu
A rectangular region that can be expanded to reveal a list of
options from which a single option can be selected. Drop-down
menus display the currently selected option with a down-arrow
to the right. Clicking on the arrow will expand the rectangular
region to reveal a list of options. Clicking on an option will select
the option and collapse the list. The list can be collapsed
without changing the currently selected option either by
reselecting the same option or by moving the cursor outside of
the menu (the menu will collapse after a few seconds).
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Scrollbar
Scrollbars are used when the size of the content within a panel
exceeds the size of the panel and allow the content to be
moved vertically or horizontally within the panel.
Slider
An element that allows a single value to be selected from a
range of values by dragging from one end to the other.
Dial
An element that emulates the behavior of a real dial. They are
similar to sliders in that they allow a single value to be selected
from a range of values. They are represented as circular
regions that can be dragged clockwise and counter-clockwise.
Tab
A type of button that allows the content of a panel to be quickly
swapped between several options.
7.2 Panels
The software displays content in a series of panels. The content is referred to
as follows:
The EKG / timeline
The 3D view
The browser
The ultrasound view (only available in ultrasound simulation packages, see
section 3 Packages)
24
7.2.1 Resizing panels
The 3D view, browser and ultrasound panels can be resized by clicking and
dragging the dividers between the panels. Horizontal dividers can be dragged
vertically and vertical dividers can be dragged horizontally. To resize three
panels simultaneously click and drag at the intersection of the horizontal and
vertical dividers.
7.2.2 Swapping the panel content
The 3D view, browser and ultrasound views can be interchanged using the 3D
view, ultrasound and browser buttons in the top right corner of each of these
panels.
Clicking on one of these buttons in any of the three panels will select the view
that is displayed within that panel. The button for the currently displayed view
will remain highlighted.
If the view selected is already visible in another panel the content of the two
panels will be swapped.
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7.2.3 Changing the panel layout
The layout of the 3D view, browser and ultrasound view is configurable allowing
a single panel to be displayed or any combination of two or three panels (note
that in the Anatomy Package the ultrasound panel is not available limiting the
software to a maximum of two panels).
Switching between panel layouts is achieved using the panel layout buttons in
the top right corner of the 3D view, browser and ultrasound panels.
3 panels split right
3 panels split left
2 panels
1 panel
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7.2.3.1 Horizontal split button
The horizontal split button divides the panel into two vertical panels.
7.2.3.2 Vertical split button
The vertical split button divides the panel into two horizontal panels.
27
7.2.3.3 Vertical expand button
The vertical expand button expands the panel vertically to the fit the full height
of the screen (this will close the panel that is above or below it).
7.2.3.4 Close panel button
The close panel button closes the panel expanding the remaining panels to fill
the screen as required.
28
7.2.3.5 Expand button
The expand button expands the panel to fill the screen. A panel can also be
expanded by double clicking within it.
7.2.3.6 Collapse button
Collapsing a panel will return to the layout prior to expanding the panel. The
panel can also be collapsed by double clicking within it.
7.2.4 Hiding and showing the toolbars
The toolbars can be hidden by pressing the toggle toolbar visibility button
in the top-left corner of the screen. Press the button a second time to show all
the toolbars.
29
8 The EKG and timeline
The horizontal panel across the bottom of the screen can either display an EKG
or a simple timeline. Unlike the 3D view, ultrasound view and browser the EKG
cannot be moved to another panel and the EKG panel cannot be used to
display any content other than the EKG or timeline.
The application can display a cardiac cycle of 60bpm. The current phase within
the cardiac cycle is indicated by the red vertical bar on the EKG referred to as
the play head. The 3D view and ultrasound view remain synchronized with the
EKG at all times.
8.1 Switching between the EKG and timeline
The EKG can be collapsed to a timeline by pressing the minus button in the
bottom-right corner. The timeline uses less space than the EKG and has the
same functionality but does not illustrate cardiac electrical activity.
To switch back to the EKG from the timeline press the plus button at the righthand end of the timeline.
To switch between the EKG and timeline simply double-click within the panel.
8.2 Hiding and showing the timeline panel
The timeline panel can be hidden by pressing the close button in the bottomright corner of the panel.
30
When hidden, the timeline can be restored using the EKG button found in the
top-left corner of the screen.
8.3 Starting and stopping playback
To begin continuous playback of the 60bpm cardiac cycle press the play
button in the bottom-right corner of the EKG/timeline panel.
During playback the play button is replaced with a pause button. This button
will stop playback and the pause button will switch back to the play button.
8.4 Jumping to a specific time
To jump to a specific moment within the cardiac cycle simply select a point on
the EKG/timeline with the LM B. If the cardiac cycle is paused the play head
will remain at the selected location. If the software is currently playing then
playback will continue from the selected location.
8.5 Scrubbing the timeline
It is possible to move backwards and forwards through the cardiac cycle by
scrubbing the timeline. To begin scrubbing from the current moment within the
cardiac cycle press and hold the LM B over the play head To begin scrubbing
from any other moment within the cardiac cycle press and hold the LM B
anywhere over the EKG/timeline. Whilst holding the LM B drag left or right
across the EKG/timeline, the play head will move with the cursor. To stop
scrubbing release the LM B; if playback is paused the play head will remain at
its current location. If the looped cardiac cycle was playing then playback will
resume.
The timeline can also be scrubbed using the mouse wheel. Whilst the cursor is
over the EKG/timeline panel scroll up or down to shift the play head backwards
and forwards through the cardiac cycle.
31
8.6 Slowing down playback
The 60bpm looped cycle can be displayed in slow-motion
Reducing the playback speed is equivalent to observing the heart
in slow-motion; it is not equivalent to reducing the heart rate.
To adjust the playback speed first show the speed slider by pressing the
speed button in the bottom-right corner of the EKG/timeline panel. The slider
can be hidden again by pressing the same button a second time.
When the speed slider is at the right end of the slider bar the cardiac cycle will
play at normal speed. To reduce the playback speed, drag the slider to the left
(to increase it drag it to the right).
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9 The 3D view
The 3D view displays an interactive real-time 3D representation of the heart and
can also display simulated TEE and TTE ultrasound probes and additional
organs depending on the package (see section 3 Packages).
9.1 Navigating around the heart
It is possible to view the heart from any angle and in any orientation. For
simplicity the ways in which the view of the heart can be manipulated are
described in terms of a virtual camera: The 3D view displays the output of a
virtual camera looking at a heart suspended in space. To view the heart from a
particular angle requires the camera to be moved to the appropriate location,
which is achieve through a series of well defined camera moves (orbit, dolly,
track, pan and roll) described below.
9.1.1 The camera toolbar
Options relating to the camera can be found in the camera toolbar. The
camera toolbar can be expanded and collapsed by pressing the camera
toolbar button at the top of the screen.
9.1.2 Manipulating the camera
Whilst the mouse is over the 3D view, press and hold the A L T key. The cursor
will change to a filled white circle indicating that the software is now in camera
manipulation mode. Releasing the A L T key will exit camera manipulation mode.
Whilst in camera manipulation mode the camera is moved by clicking and
dragging with different combinations of mouse buttons.
In certain instances the cursor may reach the edge of the screen
whilst manipulating the camera preventing further dragging in this
direction. When this occurs stop the current camera move, position
the cursor back in the center of the 3D view and then resume the
camera move from this position. It is generally easier to move the
camera using a series of short movements rather than a single
long one.
Some limitations are placed on the positions and orientations into which the
camera can be moved: the software will prevent the camera from being moved
too far away from the heart or rotated such that it is facing in the opposite
33
direction to the heart. It is also impossible for the camera to travel into the heart
without first slicing away a section of the tissue (for more information see
section 9.2 Slicing). When the camera encounters any of these constraints its
motion is restricted in some directions which may alter the effect of certain
camera moves. It is possible to return to a surgical overview of the heart at any
time by pressing the H O M E key (located above the cursor keys).
9.1.2.1 Orbit
Orbiting involves moving the camera in a circular arc around a subject whilst
maintaining a consistent distance from it. The point around which the camera
orbits in the software is determined automatically based on the distance of the
camera from the heart. When the camera is far from the heart (such that the
entire heart is visible) the camera orbits the entire heart. When the camera is
closer it will orbit a point on the heart (determined automatically by the software).
To begin orbiting press and hold the L MB whilst in camera manipulation mode
(A L T key). As a general rule drag in a direction parallel to the desired direction
in which to orbit the camera (and perpendicular to the axis of rotation), thus: to
orbit horizontally around the heart (around a vertical axis) drag left or right; to
orbit vertically (around a horizontal axis) drag up or down. To stop orbiting
release the LM B.
34
9.1.2.2 Dolly
A camera dolly involves moving the camera in a direction perpendicular to that
in which it is facing. This is primarily useful when the camera is close to the
heart allowing a particular structure to be centered in the 3D view.
To dolly the camera press and hold the M M B whilst in camera manipulation
mode (A L T key) and drag across the 3D view. The heart moves in the direction
in which the cursor is dragged (similar to dragging a 2D image across the
screen). To stop dollying release the M MB.
To center a structure within the 3D view move the cursor over the
structure, press the MM B and drag it into the middle of the 3D
view.
9.1.2.3 Track
A camera track is a movement forwards or backwards in the direction the
camera is facing; this allows the camera to be moved towards and away from
the heart.
To begin a camera track press and hold the RM B whilst in camera
manipulation mode (A L T key). To track-in (move the camera forward) drag the
35
cursor upwards; to track-out (move the camera backwards) drag the cursor
downwards; to stop tracking release the RM B.
The camera advances directly forwards in the direction it faces so
to examine a particular structure it is simplest to center the desired
subject in the 3D view (see section 9.1.2.2 Dolly) before trackingin.
9.1.2.4 Pan
Panning entails rotating the camera without changing its location in space. The
visual effect of a pan is very similar to that of a dolly (with a dolly the camera
changes location but does not rotate; with a pan the camera rotates but does
not change location). Like the dolly this is primarily useful when the camera is in
close proximity to the heart.
A pan functions similar to a dolly: press and hold the L MB and M M B together
whilst in camera manipulation mode (A L T key) and drag across the 3D view; to
stop panning release the L MB and MM B.
36
9.1.2.5 Roll
A camera roll involves rotating the camera about the direction in which it is
facing. The visual effect is to rotate the image clockwise and counter-clockwise.
To begin rolling the camera press and hold the LM B and R MB together whilst
in camera manipulation mode (A L T key) then drag the cursor in a circular arc
around the mid-point of the 3D view. The heart will rotate in the direction the
cursor moves. To stop rolling the camera release the L MB and RM B.
As a result of the way in which the camera roll functions the closer
the cursor is to the mid-point of the 3D view the faster the camera
will rotate, thus greater control is possible by positioning the cursor
near the outer edge of the 3D view.
9.1.3 Constraining the camera to the ultrasound probe
Ultrasound simulation packages only (see section 3 Packages).
The camera can be constrained to the simulated ultrasound probe such that it
always looks down on the plane of ultrasound maintaining this position as the
plane moves (for more information on simulated ultrasound see section 11
Ultrasound Simulation). This mode is enabled by pressing one of the
constraint buttons on the camera toolbar: The camera can either be
constrained to the probe such that the plane of ultrasound travels vertically up
the screen or vertically down the screen. When either camera constraint is
enabled the slicing mode will default to ultrasound (see for more information).
Whilst the camera is constrained and the slicing mode is set to
ultrasound inverting the slice-plane will move the camera to the
opposite side of the slice-plane.
37
To disable a camera constraint press the currently selected constraint button in
the camera toolbar a second time.
Whilst the camera is constrained to the probe the camera position
cannot be manipulated other than by moving the probe.
9.2 Slicing
The heart can be sliced open down any plane to reveal its interior structure (the
tissue on one side of the plane is hidden whilst the tissue on the opposite side
remains visible). When the heart is sliced the camera may be positioned within
the region that is hidden allowing close-up views of the interior structure.
9.2.1 The slice toolbar
Slicing options are selected using the slice toolbar which can be shown and
hidden using the slice button in the top-left corner of the screen. The slice
toolbar consists of a drop-down menu for selecting the current slicing mode
and buttons for inverting and resetting the slice-plane.
9.2.2 Slice modes
The slicing mode is selected from the drop-down menu in the slice toolbar and
determines the way in which the slice-plane is manipulated.
When switching the slicing mode the immediate effect on the slice-plane will
vary depending on the previous slice position and mode. The slice-plane will
either maintain its previous position or, if the slicing mode limits the position of
the plane such that this is not possible, it will move to a position that matches
the previous position as closely as possible.
38
In camera slicing mode and manipulator slicing mode the current position of the
slice-plane is indicated by a grey circle (the circle lies on the plane). To
manipulate the slice-plane press and hold the S H I F T key whilst the cursor is
over the 3D view. The cursor will change to an empty white circle to indicate
that the software is now in slice manipulation mode (to exit slice manipulation
mode release the S H I F T key). When in slice manipulation mode the sliceplane can be positioned by clicking and dragging with the LM B or RM B. The
behavior of the slice-plane varies depending on the current slicing mode (see
below). In certain instances the camera will move as the slice position chances
to avoid the camera becoming embedded within the volume of the heart.
The slice-plane can be positioned such that it is entirely outside of
the heart. In this instance, depending on the orientation of the
plane, the heart will either be entirely hidden or entirely visible.
9.2.2.1 None
When none is selected as the current slicing mode the slice-plane is disabled.
The heart is not sliced and invert button and reset button on the slice
toolbar have no effect.
9.2.2.2 Camera slicing mode
When camera slicing mode is enabled the slice-plane remains at a fixed
distance in front of the camera and is oriented so that the camera always views
the cut surface en-face.
39
To change the distance of the slice-plane from the camera press and hold the
LM B whilst in slice manipulation mode (S H I F T key). A slice-plane manipulator
in the form of a transparent white circle will appear within the 3D view indicating
the current position of the slice-plane. The white line in the center of the circle
indicates the direction to drag the cursor in order to bring the slice-plane closer
to the camera; to push the slice-plane further away from the camera drag in the
opposite direction. When the L M B is released the distance of the slice-plane
from the camera will remain fixed and any changes to the camera position will
also affect the slice-plane.
To reset the slice-plane such that it slices directly through the center of the heart
press the reset slice-plane button on the slice toolbar.
40
9.2.2.3 Manipulator slicing mode
Manipulator slicing mode allows the slice-plane to be moved to an arbitrary
position and orientation relative to the heart.
To move the slice-plane press and hold the LM B whilst in slice manipulation
mode (S H I F T key). A slice-plane manipulator in the form of a transparent circle
will appear at the current level of the slice-plane. The white line in the center of
the circle indicates the direction to drag the cursor in order to reveal more of the
heart; to slice deeper into the heart drag the cursor in the opposite direction.
Depending on the position of the slice-plane the direction in which to drag will
vary. To stop moving the slice-plane, release the LM B .
41
To rotate the slice-plane press and hold the RM B whilst in slice manipulation
mode (S H I F T key). A transparent circle will appear within the 3D view
corresponding to the current orientation of the slice-plane. To rotate the sliceplane about a horizontal axis drag up or down; to rotate about a vertical axis
drag left or right; to rotate about any other axis drag in a direction perpendicular
to the axis of rotation; to stop rotating the slice-plane release the R MB .
Rotation of the slice-plane is camera-relative (the axis of rotation is always
perpendicular to the direction the camera is facing). In certain instances it is
easiest to rotate the camera before attempting to rotate the slice-plane. Rotation
of the slice-plane is most intuitive when looking down on it from above.
The pivot point around which the slice-plane rotates is determined by the cursor
position when the R MB is first pressed. If the cursor is within the grey circle
then the slice-plane will rotate around this point; if the cursor is outside the grey
circle the nearest point within the grey circle will be used. The current pivot point
is indicated by the mid-point of the transparent circle when the R M B is held
down.
The slice-plane can be inverted by pressing the invert button on the slice
toolbar.
The reset slice-plane button will reset the slice-plane to a position slicing
directly through the heart.
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9.2.2.4 Ultrasound slicing mode
Not available in the Anatomy package (see section 3 Packages).
When ultrasound slicing mode is enabled the slice-plane is aligned to the plane
of ultrasound emitting from the currently enabled ultrasound probe (see section
11 Ultrasound Simulation). The plane will follow any movements of the
ultrasound plane and the cut surface of the heart will correspond to the current
ultrasound image. It is possible to constrain the camera to the ultrasound probe
such that the cut surface is always viewed en-face as the ultrasound probe
moves (see section 9.1.3 Constraining the Camera to the Ultrasound Probe for
details).
When ultrasound slicing mode is used in conjunction with TEE ultrasound
simulation it is possible to manipulate the TEE probe using slice manipulation
mode (see section 11.3.3 Moving the Probe for details).
The slice-plane can be inverted to slice away the opposite side of the
ultrasound plane by pressing the invert button on the slice toolbar.
43
Pressing the reset slice-plane button when in ultrasound slice mode will
reset the ultrasound probe and slice-plane to its default location.
9.3 Intracardiac structure visibility
It is possible to show and hide major intracardiac structures within the 3D view.
The structures to which this applies are the atria, ventricles, valves, veins,
arteries and fat. Any combination of these structures can be shown and hidden
e.g. a single atrium can be removed to reveal the interior structure or a single
valve can be shown in isolation. For more information on how to show and hide
structures see the main section, 12.2.
44
10 The browser
The main purpose of the browser is to display pages from the built-in cardiac
anatomy textbook, allowing structures to be examined with reference to the 3D
and ultrasound views.
The browser displays information in a series of tabs. Each tab contains a
different page making it easy to switch between them. The currently opened
tabs are displayed across the top of the browser. Selecting a tab will display the
associated page. If more tabs are open than can be displayed across the top of
the browser the switch tab button is displayed which, when selected, displays
a drop-down list of all the pages that are currently open. Pages can be opened
in several ways but the open page button provides quick and simple access
to all pages via a drop-down menu. Tabs can be closed by pressing the close
current page button. To open a particular page select it from the drop-down
menu and it will open in a new tab (if the page is already open the existing tab
will be selected instead of creating a new one).
Pages can be scrolled up and down using the scrollbar on the right side of the
page (the P A G E U P , P A G E D O W N , H O M E , E N D keys and scroll wheel can
also be used).
10.1 Changing language and nomenclature
The text within the software can be switched between UK English and US
English and the nomenclature can be switched between anatomical and clinical
terminology.
45
To change the language and nomenclature open the options page (press the
open page button and select options from the drop-down menu). The
options page contains toggle buttons that specify the language and
nomenclature. These settings will be restored each time the application starts.
10.2 Highlighting and selecting intracardiac
structures
Structures can be highlighted and selected from pages within the browser view.
To highlight a structure simply hover over its name. The name will turn blue to
indicate that it is currently highlighted. To select a structure select its name with
the L MB . The name will turn red to indicate that the structure is currently
selected. To deselect a structure press the LM B in any empty area of the
browser. Highlighting and selection is described in more detail in section 12..1.
10.3 Default views
Each structure has an associated view which demonstrates the location of the
structure on the 3D view. To go to the default view for a structure first select the
structure in either the intracardiac structures page or a page within the anatomy
textbook. Once selected the default-view-button will be visible to right of the
structure’s name. When pressed the 3D view will transition to a view that
illustrates the location of the structure. For more information about default views
see section 12.3.
46
10.4 Intracardiac structure visibility
It is possible to show and hide intracardiac structures from pages within the
browser. Structures that can be shown and hidden have a visibility button to
the left of their name. The visibility button indicates whether the structure is
currently visible and when selected with the LM B will toggle the structure’s
visibility on and off. It is also possible to isolate a particular structure by holding
the C T R L key whilst clicking on its visibility button with the L MB (this hides
all other structures). For more information see section 12.2.
10.5 The intracardiac structures page
The intracardiac structures page contains a hierarchical list of annotated
intracardiac structures. It functions as an index for the anatomy textbook and
also provides additional functionality relating to the intracardiac structures. The
list is arranged hierarchically (large structures can be expanded to show a list of
sub-structures). In cases where a structure is considered a sub-structure of
multiple larger structures it is duplicated at each relevant location (thus certain
structures appear more than once within the list).
10.5.1 Expanding and collapsing lists
Structures that have an associated list of sub-structures have a toggle substructures button to the left of their name. Pressing the button once will show
the list of sub-structures and pressing it again will collapse the list back to its
original state.
47
To expand the lists of sub-structures for all the top-level structures press the
toggle all sub-structures button in the top-left corner of the intracardiac
structures page. Press the button again to collapse all lists of sub-structures. To
expand all lists (at all levels of the hierarchy) press and hold the C T R L key
when clicking on the toggle all sub-structures button.
10.5.2 Showing and hiding multiple structures
It is possible to change the visibility of all structures simultaneously using the
show/hide all button at the top of the intracardiac structures page. Clicking
on the show/hide all button with the LM B will toggle the visibility of all
structures on or off; clicking on the show/hide all button with the LM B whilst
holding the C T R L key will toggle the visibility of each individual structure.
10.6 Getting information about a structure
To show the section in the cardiac anatomy textbook relating to a structure first
select the structure in the intracardiac structures page. Once the structure is
selected the information button will be visible to the right of its name. Clicking
on the information button will open the appropriate page in the textbook in a
new tab (or, if the page is already open, the existing tab will be displayed).
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10.6.1 Echocardiography Imaging planes
Not available in the Anatomy package (see section 3 Packages).
Several structures within the cardiac anatomy textbook contain subsections
entitled ‘TEE imaging planes’ and 'TTE imaging planes' which list the ultrasonic
imaging planes typically used to examine the structure. Left-clicking on one of
the imaging planes will move the simulated ultrasound probe to the appropriate
position thus demonstrating the corresponding ultrasound image in ultrasound
view (see section 11 Ultrasound Simulation).
The complete list of standard imaging planes can also be accessed directly
from predefined slide pages (see section 12.7).
49
11 Ultrasound simulation
11.1 The ultrasound view
Not available in Anatomy Package (see section 3 Packages).
The software can generate ultrasound images from both a simulated multi-plane
transesophageal ultrasound probe and a simulated transthoracic ultrasound
probe (availability of ultrasound simulation modes is dependent on package,
see section 3 Packages).
The ultrasound view shows the output from the simulated ultrasound probes in
a similar fashion to a standard ultrasound monitor displaying the V-shaped
ultrasound image with distance markings at 1cm intervals.
The ultrasound images generated by the software are not pre-registered but are
generated in real-time from the virtual heart model. The results are
diagrammatic whilst maintaining a level of realism in terms of image quality.
11.1.1 Structure visibility
The ultrasound view is not affected by structure visibility (see Section 12.2).
Intracardiac structures within the ultrasound view remain visible at all times
regardless of whether or not they are currently visible within the 3D view.
50
11.1.2 Inverting the ultrasound image
Both the TEE and TTE ultrasound images can be inverted vertically by pressing
the / key.
The TTE ultrasound image can be inverted horizontally by pressing the . key.
11.1.3 Setting the initial orientation
The initial orientation of the ultrasound image (when the software is launched)
can be set from the options page. To open the options page press the open
page button in the browser and select options from the drop-down menu. The
initial orientation of the ultrasound image is set using the horizontal and vertical
inversion toggle buttons. Press a toggle button once to swap the initial
inversion state, press it a second time to restore it to its previous setting.
11.1.4 Depth-of-field
The depth-of-field of the ultrasound image can be decreased to a minimum of
6cm using the decrease depth-of-field button and increased to a maximum
of 20cm using the increase depth-of-field button.
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11.2 The ultrasound control panel
11.2.1 Opening and closing the control panel
The ultrasound control panel can be shown by pressing the ultrasound
control panel button located at the top of either the 3D view or the ultrasound
view. Pressing the button on either panel will display the control panel docked
within that panel, thus the button can be used to switch the ultrasound control
panel between the 3D view and ultrasound view. The control panel is closed by
pressing the close button in the top right corner of the panel.
The visibility of the simulated ultrasound probes in the 3D view is
linked to the visibility of the ultrasound control panel. Showing the
control panel will show the probe and closing it will hide the probe.
11.2.2 Selecting the ultrasound simulation mode
At the top of the ultrasound control panel are tabs for selecting the currently
enabled ultrasound simulation mode. Only one ultrasound simulation mode can
be enabled at any one time. Depending on the package (see section 3
Packages) these tabs may be greyed out indicating that the corresponding
ultrasound simulation mode isn't available.
52
11.3 TEE simulation
TEE simulation packages only (see section 3 Packages).
TEE simulation mode is enabled by selecting the TEE tab at the top of the
ultrasound control panel.
When enabled the ultrasound panel displays an orientation indicator that shows
the current rotation of the simulated TEE ultrasound plane. When in TEE
simulation mode only cardiac tissues are visible on the ultrasound image.
53
11.3.1 The simulated TEE probe
When TEE simulation is enabled the TEE probe can be displayed within the 3D
view to demonstrate its position relative to the heart. The visibility of the probe is
linked to the visibility of the ultrasound control panel (see section 11.2 The
Ultrasound Control Panel). The probe can be manipulated from the TEE tab of
the ultrasound control panel or using a manikin simulator. The TEE probe
has the following degrees of freedom:
•
•
•
•
Travel up and down the esophagus.
Twist left and right.
Anteflexion and retroflexion.
Rotation of the plane of ultrasound from 0 to 180 degrees.
Lateral flexion is not supported.
54
11.3.2 The TEE tab
11.3.3 Moving the probe
The TEE tab allows manipulation of the probe by holding the LM B and
dragging any of the controls. Fine adjustments can be made by positioning the
cursor over a control and scrolling up and down with the mouse wheel.
The control panel mimics the controls on a standard TEE ultrasound probe
when used from the head end of a patient. The circle at the top of the panel
represents the patient’s mouth, the horizontal white line indicates the level of
the teeth, the vertical black bar represents the shaft of the probe, the dial at the
bottom of the panel represents the flexion dial and the buttons on the left side
rotate the plane of ultrasound.
The depth slider
The distance the probe is inserted into the esophagus is
indicated by the distance markings on the vertical black
slider at the level of the horizontal white line. To increase
the depth click and drag the black slider upwards
(towards the mouth). To decrease the depth drag the
slider downwards (away from the mouth).
When in ultrasound slice mode the depth can also be
adjusted by clicking dragging vertically across the 3D
view with the LM B (see section 9.2.2.4 Ultrasound
Slicing Mode).
55
The twist dial
The probe can be twisted left and right using the small
black dial at the base of the depth slider. Click and
drag the dial in a circle to twist the probe.
When in ultrasound slice mode the probe can also be
twisted by dragging horizontally across the 3D view with
the MM B (see section 9.2.2.4 Ultrasound Slicing
Mode).
The flexion dial
The probe tip can be anteflexed and retroflexed using
the large dial at the bottom of the panel. Click and drag
the dial in a clockwise direction to anteflex the probe tip;
drag in an anticlockwise direction to retroflex the probe
tip.
When in ultrasound slice mode the probe can also be
flexed by dragging horizontally across the 3D view with
the RM B (see section 9.2.2.4 Ultrasound Slicing
Mode).
The lock button
The button to the right of the flexion dial allows the
flexion to be locked or unlocked. When locked the probe
maintains its flexion after the flexion dial is released.
When unlocked the probe will return to its rest state
whenever the flexion dial is released.
56
The rotation buttons
The plane of ultrasound can be rotated using the
buttons on the left of the control panel. To increase the
angle of rotation press and hold the top button, to
decrease it press and hold the bottom button. The
simulated transducer can be rotated from 0° to 180°.
The middle button will reset the angle of rotation to 0°.
The current angle of rotation is indicated on the
ultrasound view.
11.3.4 The TEE manikin
TEE manikin simulator packages only (see section 3.5 TEE Manikin Simulator package ).
The TEE manikin allows the simulated TEE probe to be manipulated using a
life-size, upper-body torso and realistic TEE probe with authentic controls.
Before enabling the TEE Haptic Device, ensure that the TEE
probe tip is inserted into the mouth of the manikin.
Failure to do so may result in incorrect tracking data.
11.3.4.1 Enabling and disabling
To enable the manikin press the simulator connection button in the top-left
corner or the ultrasound control panel whilst in TEE simulation mode. If the
57
manikin is detected the button will show a connected icon and the simulated
probe will move to the current position of the physical probe within the manikin.
To disable the manikin press the simulator connection button a second time.
The button will show a disconnected icon and the simulated probe will stop
responding to the manikin.
When the manikin simulator is enabled the controls on the TEE tab will no
longer function but will continue to reflect the current state of the simulated TEE
probe. All other controls within the software will continue to function as normal.
This allows the software to be used by two people simultaneously (one person
using the manikin simulator, one person using the mouse and keyboard).
11.3.4.2 Simulated probe controls
The controls on the manikin simulator function in the same way as a standard
multi-plane probe. Once inserted in to the manikin’s mouth, the simulator probe
can travel to a position deep within the stomach. The probe can be twisted left
and right in the esophagus. The lateral flexion dial is not functional.
11.3.5 Standard imaging planes
The standard TEE imaging planes are built into the software, for more
information see section 12.7 Predefined Slide Pages.
11.4 TTE simulation
TTE simulation packages only (see section 3 Packages).
TTE simulation is enabled by selecting the TTE tab at the top of the ultrasound
control panel.
58
When TTE simulation is enabled the ultrasound panel displays a HeartWorks
icon to one side of the apex of the ultrasound image. Which side of the apex
this icon is displayed will depend on whether the ultrasound image is inverted
horizontally (see section 11.1.2 Inverting the Ultrasound Image). However, this
icon will always correspond to the index marker on the side of the TTE probe.
11.4.1 Additional organs
When TTE simulation is enabled the 3D and ultrasound views display several
additional structures such as lungs, diaphragm, ribs and liver (inhalation and
exhalation are not simulated).
59
These structures are displayed as a transparent overlay on the 3D view which
fades-out based on the proximity of the camera: when the camera is completely
outside the region occupied by these structures the structures will be visible,
when the camera is inside the region occupied by these structures they will be
invisible).
These structures are also represented in the ultrasound view. The effects of
variations in acoustic impedance are emulated on the ultrasound image such as
shadowing and reverberation from bone and scattering within regions of lung.
scattering
shadowing
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11.4.2 The simulated TTE probe
When TTE simulation is enabled and the TTE probe is in a registered position
on the chest (see section 11.4.4.1 Registered Positions) the TTE probe can be
displayed in the 3D view to demonstrate its position relative to the heart and
additional structures. The simulated probe will only be displayed if the
ultrasound control panel is visible (see section 11.2 The Ultrasound Control
Panel). The probe is manipulated using a manikin simulator.
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11.4.3 The TTE tab
When TTE simulation is enabled the TTE tab displays a three-quarters view of
the torso and rib-cage. When the TTE probe is in a registered position (see
section 11.4.4.1 Registered Positions) on the chest a red dot indicates the
position of the probe relative to these structures.
Before enabling the TTE Haptic Device, ensure that the TTE
probe tip is resting on the soft area of the manikin.
Failure to do so may result in incorrect tracking data.
11.4.3.1 Enabling and disabling
To enable the manikin press the simulator connection button in the top-left
corner of the ultrasound control panel whilst in TTE simulation mode. If the
manikin is detected the button will show a connected icon. If the probe is in a
62
registered position (see below) the simulated probe will move to the current
position of the physical probe relative to the torso.
To disable the manikin press the simulator connection button a second time.
The button will show a disconnected icon and the simulated probe will stop
responding to the manikin and remain at its current location.
When the manikin simulator is enabled all other controls within the software will
continue to function as normal. This allows the software to be used by two
people simultaneously (one person using the manikin simulator, one person
using the mouse and keyboard).
11.4.4 The TTE manikin
The TTE probe location and orientation can be manipulated using a manikin
consisting of a life-size, upper-body torso and realistic TTE probe.
The TTE probe can be moved freely and the clarity of the resulting ultrasound
images reflects the pressure of the probe against the torso and the angle of the
probe relative to the surface. If insufficient pressure is applied or the angle is
extreme the clarity of the ultrasound image will be affected.
The manikin may be tilted into a partial left lateral position to reproduce a
commonly used patient position for scanning. In the simulator software this
manikin position does not shift the virtual heart within the chest (the ultrasound
image is unaffected).
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11.4.4.1 Registered positions
The software will only display TTE images when the probe is on, or in close
proximity to the regions of the chest illustrated above. Any point within this
region is referred to as a registered position. When the probe is in a registered
position the TTE tab will display a red-dot at the location of the TTE probe (see
section 11.4.3 The TTE Tab) and the simulated TTE probe can be displayed in
the 3D view (see section 11.4.2 The Simulated TTE Probe). When the probe is
outside of the defined region the TTE tab will not show a red dot and the
simulated TTE probe will not be shown in the 3D view.
11.4.5 Standard imaging planes
Predefined TTE imaging planes are built into the software, for more information
(see section 12.7 Predefined Slide Pages).
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12 Structures
All the major intracardiac structures within the heart are documented and can
be highlighted and selected from within the 3D view, ultrasound view and
browser. Major structures can also be shown and hidden within the 3D view.
In TTE simulation mode the ultrasound and 3D view display
additional structures (see section 11.4.1 Additional Organs). These
additional structures cannot be selected and highlighted.
12.1 Highlighting and selecting intracardiac
structures
One structure may be in a highlighted state and one structure may be in a
selected state at any time. The selected and highlighted structures will always
remain consistent between the 3D view, ultrasound view and browser.
12.1.1 Selection mode
Structures can be highlighted and selected within the 3D view and ultrasound
view using selection mode (for information on highlighting and selecting
structures from the browser see section 10.2). To enter selection mode press
and hold the S P A C E B A R . To leave selection mode release the S P A C E B A R .
When in selection mode the looped cardiac cycle (see section 8 The
EKG and Time Line) will be paused if it is playing. Playback will
resume once selection mode is exited.
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12.1.2 Highlighting
To highlight a structure enter selection mode and move the cursor over the
structure in either the 3D view or ultrasound view (for information on highlighting
structures using the browser see section 10.2). The structure at the current
cursor position will highlight in blue. Hold the cursor stationary for a short
duration to display a tool-tip indicating the name of the structure that is currently
highlighted.
In TTE simulation mode the ultrasound view displays additional
structures (see section 11.4.1 Additional Organs). These structures
cannot be highlighted but some of them will display a tool-tip.
12.1.3 Selection
To select a structure first highlight it within either the 3D view or ultrasound view
and then press the LM B (to select structures using the browser see section
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10.2 Highlighting and Selecting Intracardiac Structures). The selected structure
will be outlined in red in the ultrasound view and shaded darker than the
surrounding tissue within the 3D view. Where the structure is occluded by other
structures within the 3D view its extents will be indicated by an outline.
12.1.4 Overlapping structures
In many cases multiple structures overlap the same region (this is common
when one structure is a sub-structure of another). This means that there are
often several structures at any one point within the 3D view or ultrasound view.
It is possible to cycle through the structures at a location by selecting the same
location repeatedly with the LM B.
12.2 Intracardiac structure visibility
It is possible to show and hide certain intracardiac structures within the 3D view
directly from the 3D view and ultrasound view (to show and hide structures from
the browser see section 10.4). The structures to which this applies are the atria,
ventricles, valves, veins, arteries and fat. Any combination of these structures
can be shown or hidden e.g. a single atrium can be removed to reveal the
interior structure, or a single valve can be shown in isolation. Structure visibility
only affects the 3D view; structures cannot be hidden within the ultrasound view.
The visibility of the currently selected structure (or the major structure of which it
is a part) can be toggled by pressing the toggle selected structure visibility
button on the camera toolbar.
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To hide an unselected structure from either the 3D view or ultrasound view,
highlight the structure (or any of its sub-structures) and press the RM B.
To toggle the visibility of all structures press the toggle all visibility button on
the camera toolbar.
12.3 Default views
Each intracardiac structure has an associated 3D view which clearly illustrates
the location of the structure.
To go to the default view for the currently selected structure press the default
view button on the camera toolbar.
To go to the default view of any other structure highlight the structure in either
the 3D view, ultrasound view or browser and press the MM B Slides.
Slides allow the state of the software to be stored so that it can be restored
subsequently. This can be used to store the state of the software between uses
and to create interactive slideshows.
12.4 The slide toolbar
The slide page functionality is accessed via the slide toolbar which can be
toggled on and off using the slide toolbar button at the top of the screen.
Slides are grouped into pages which are loaded and manipulated using the
slide page drop-down menu at the left side of the slide toolbar. The
individual slides within a page are selected from the slide drop-down menu
and manipulated using the buttons at the right side of the toolbar.
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12.5 Slide pages
Slide pages contain sets of slides and are manipulated through the left most
drop-down menu on the slide toolbar.
12.5.1 1Creating slide pages
To create a new slide page select New page from the slide page drop-down
menu. Type a name for the slide page and press the E N T E R key (or click
outside the menu with the LM B) to accept.
When a slide is shown the manikin is automatically disabled.
Creation of a new slide using the manikin following review of slides
will require the manikin to be enabled once again.
2.5.2 Deleting slide pages
To delete a slide page, first select the slide page to be deleted from the slide
page drop-down menu. Then select Delete current page from the slide
page drop-down menu. The software will ask for confirmation before deleting
the slide page.
This operation cannot be undone. Once a slide page has been
deleted it cannot be recovered.
12.5.3 Renaming slide pages
To rename a slide page select the page from the slide page drop-down
menu. Double click on the slide page name with the LM B and enter the new
name. Press the E N T E R key (or click outside the menu with the L BM ) to
accept the change. Press the E S C key to cancel changes.
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12.5.4 Locking slide pages
To prevent accidental modification of slides within a slide page the slide page
can be locked. Once locked no further modification to the slide page can occur
until the page has been unlocked. To lock a page select the page from the slide
page drop-down menu and press the lock button to the right of its name. To
unlock the page press the lock button again.
12.6 Slides
Slides store the application state making it simple to return to that subsequently.
When a slide is shown the manikin is automatically disabled.
Creation of a new slide using the manikin, following review of the
slides, will required the manikin to be enabled once again.
12.6.1 1Creating slides
The content of a slide is determined by the application state at the time the slide
is created (it contains a snapshot of the current state of the software). When a
slide is created it will be added to the currently selected slide page. To create a
slide press the add slide button to the right of the slide drop-down menu.
Enter a name for the slide and press the E N T E R key (or click outside the menu
with the LM B). See section 12.6.6 Setting the Content of Slides for an
explanation of how to specify what information is stored within the slide.
12.6.2 Showing slides
To restore a previously created slide select the slide from the slide drop-down
menu. The application will transition smoothly from its current state to the state
stored within the slide.
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12.6.3 Deleting slides
To delete a slide, first select the slide from the slide drop-down menu and
then press the delete slide button to the right of the menu.
This operation cannot be undone and you will not be prompted for
confirmation.
12.6.4 Renaming slides
To rename a slide select it from the slide page drop-down menu then double
click on the slide name with the L MB and enter a new name. Press the
E N T E R key (or click outside the menu with the L BM ) to accept the change or
press the E S C key to cancel the change and restore the original slide name.
12.6.5 Changing the order of slides
press
drag
release
To move a slide within a slide page open the slide drop-down menu and then
click and drag the slide to a different location within the menu using the LM B.
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12.6.6 Setting the content of slides
Use the content toggle buttons to the right of the slide name to specify what
information is stored within a slide. Each button can be turned on and off
independently and corresponds to a different aspect of the application state.
When a slide is shown only the content associated with the enabled content
toggle buttons is restored.
Structure visibility and the selected structure.
When enabled the visibility of each structure within the 3D view and
which structure is currently selected (if any) is stored.
Slice mode and slice position.
When enabled the current slice mode and position of the slice-plane
and the simulated ultrasound probe is stored.
The playback state.
When enabled the current moment within the cardiac cycle and
playback settings (playing/paused, speed) are stored.
The camera position.
When enabled the position of the camera is stored.
The layout of the GUI.
When enabled stores which panels are visible and their position and
size on the screen.
12.6.7 Modifying the content of slides
To modify the content of an existing slide select the slide from the slide dropdown menu. To remove information from the slide turn off the appropriate
content toggle buttons on the right hand side of the slide. To change the
currently stored information first remove the existing information from the slide,
set the application to the desired state and then store the new state by enabling
the appropriate content toggle buttons.
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12.7 Predefined slide pages
The software incorporates predefined slide pages.
12.7.1 Intracardiac structures
The default views for the intracardiac structures (see section 10.3 Default Views)
can be accessed by selecting intracardiac structures from the slide page
drop-down menu on the slide toolbar. To show the default view of a
particular structure select the structure from the slide drop-down menu.
12.7.2 TEE standard imaging planes
TEE simulation packages only (see section 3 Packages).
20 standard imaging planes and 6 additional commonly used views are
predefined within the software. These can be accessed by selecting standard
imaging planes from the slide page drop-down menu on the slide toolbar.
To show one of the standard imaging planes select the relevant slide from the
slide drop-down menu.
12.7.3 TTE standard imaging planes
TTE simulation packages only (see section 3 Packages).
19 TTE imaging planes (referred to within the textbook) are predefined within
the software. These can be accessed by selecting standard imaging planes
from the slide page drop-down menu on the slide toolbar. To show one of
the standard imaging planes select the relevant slide from the slide dropdown menu.
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13 Screen capture
The screen capture facility allows full-screen, static images (referred to as
screenshots) to be captured to an external USB storage device.
Screenshots are stored as Portable Network Graphic files (.png). This format is
widely supported, and uses lossless compression which reduces file size whilst
preserving image quality.
13.1 1Preparing to take screenshots
Screenshots are captured directly to an external USB storage device. Before
taking a screenshot it is necessary to connect a storage device to one of the
USB ports on the HeartWorks system.
Any device that can be recognized as an external USB storage device can be
used (e.g. USB memory sticks, external hard drives). The file-system on the
USB storage device must be either FAT32 or NTFS.
Screenshots are written to a directory called ‘HeartWorks’ on the external USB
storage device. If this directory does not exist prior to capture it will be created
when a screenshot is taken.
If HeartWorks cannot write to the external storage device for any
reason screen capture will fail. See section 13.6 Troubleshooting
Screenshots.
13.2 Taking a screenshot
To capture the current screen either press the screenshot button on the
camera toolbar (see section 9.1.1 The Camera Toolbar) or press the P R I N T
S C R E E N key on the keyboard.
If the playback state is currently set to play (see section 8.3 Starting and
Stopping Playback) or the software is transitioning between different slides, the
screenshot will be taken at the moment the screenshot button is pressed
(playback and transitions will pause briefly before resuming).
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When a screenshot is taken the HeartWorks logo will appear in the bottom left
corner of the screen and the screenshot button will start to animate. Although
the screenshot is taken at the instant the screenshot button is pressed, it may
take a few seconds to write the resulting image to the external USB storage
device. During this time the HeartWorks logo will continue to be displayed and
the screenshot button will continue to animate. The software can be used as
normal during this time.
Do not disconnect the USB storage device whilst the HeartWorks
logo continues to be displayed and the screenshot button
continues to animate. Doing so risks loss of data and damage to the
USB storage device.
13.3 Multiple screenshots
It is possible to take subsequent screenshots while HeartWorks is in the
process of writing previous screenshots to the external USB storage device. To
do this, follow the instructions for taking a single screenshot (see section 13.2).
The HeartWorks logo will continue to be displayed and the screenshot button
will continue to animate until all screenshots have been written to the external
USB storage device.
The system can write five screenshots to the external USB device
simultaneously. If the screenshot button is pressed more than five
times in rapid succession it is possible that some screenshots will not
be saved.
13.4 Transferring screenshots
To transfer screenshots to another computer wait until the HeartWorks logo is
no longer displayed in the bottom left corner of the screen and the screenshot
button is no longer animating.
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Remove the external USB storage device and connect it to another computer.
All screenshots will be located in the ‘HeartWorks’ directory (in the root path).
13.5 How screenshots are named
Screenshots are named based on the currently selected intracardiac structure
(see section 12.1 Highlighting and Selecting Intracardiac Structures).
13.5.1 No intracardiac structure selected
If no structure is selected screenshots will simply be named sequentially as a
four digit number starting at one. Thus by default the first screenshot to be
taken will be saved as the file: 0001.png, the second screenshot as 0002.png,
th
the 113 screenshot as 0113.png.
If a file already exists within the ‘HeartWorks’ directory with a name that clashes
with that of the current screenshot, the existing file will not be modified, instead
HeartWorks will use the next available file name. For example if the following
files already exist within the ‘HeartWorks’ directory:
0001.png
0002.png
0004.png
The next screenshot will be written as the file 0003.png and the subsequent
screenshot as 0005.png i.e.
0001.png
0002.png
0003.png
0004.png
0005.png
first screenshot
second screenshot
In certain instances this may make it difficult to determine the
most recent screenshots, however most computers will support
sorting files by date and time when reviewing the screenshots.
13.5.2 With an intracardiac structure selected
If a structure is selected when a screenshot is taken the name of the structure
will be appended to the resulting file's name. For example if the left ventricle is
selected when the screenshot is taken and the following files already exist
within the ‘HeartWorks’ directory:
0001.png
0002.png
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The screenshot will be written as: 0003_leftVentricle.png i.e.
0001.png
0002.png
0003_leftVentricle.png
13.6 Troubleshooting screenshots
The software may not be able to write screenshots to the external USB storage
device for several reasons. When this occurs the HeartWorks logo will not be
displayed in the bottom left hand corner of the screen and the screenshot
button will not animate. If this does happen check the following:
Is the external USB storage device connected to the HeartWorks system?
Is the USB storage device formatted as either FAT32 or NTFS?
Is there enough disk-space left on the USB storage device to store a
screenshot? (Screenshots are usually around 400kb in size depending on
the content).
Is the USB storage device writeable? Check that the device is not write
protected and that the ‘HeartWorks’ directory is not set to read-only.
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14 Appendix A - Shortcuts
Action
Key
ALT + F4
Exit software
Open documentation
F1
TEE ultrasound mode
O
TTE ultrasound mode
P
SPACEBAR
Selection mode
S
Show intracardiac structures page
Toggle visibility of GUI components
GUI
Collapse/expand
Slide toolbar
1
Slicing toolbar
2
Camera toolbar
3
Toggle visibility of timeline/EKG
4
Reset (camera, slice, visibility)
HOME
Camera manipulation
mode
Camera
F
Constrain to probe
K
Constrain to probe
(inverted)
L
Slice
mode
Slicing
Rotation
ALT
Frame all/current selection
Slice manipulation mode
3D view
TEE probe
ESC
SHIFT
None
R
Manipulator
Q
Ultrasound
W
Camera
E
Reset slice-plane
T
Invert slice-plane
I
Increase
+
Decrease
-
78
Reset
Y
Toggle lock
Depth-of-field
Ultrasound
view
Increase
]
Decrease
[
Invert TEE and TTE image vertically
/
Invert TTE image horizontally
.
RIGHT
Next slide
Slides
Previous slide
LEFT
Cancel changes to slide/slide-page name
ESC
Accept changes to slide/slide-page name
ENTER
PAGE
Scroll up
Browser
UP
PAGE
Scroll Down
DOWN
Go to start of page
HOME
Go to end of page
END
PRINT
Take screenshot
Structures
0
Toggle visibility
SCREEN
All structures
A
Selected structure
V
Deselect selected structure
D
79
15 Appendix B – GUI
80
81
Appendix B – GUI (continued)
25. Constrain camera to probe
1.
HeartWorks logo and credits
button
2.
Toggle visibility of GUI components
3.
Help drop-down menu
4.
Expand/collapse slide toolbar
28. Set panel contents to ultrasound view
5.
Lock/unlock slide page
29. Set panel contents to browser
6.
Slide page drop-down menu
30. Vertically expand panel
7.
Toggle store structure visibility
state in slide
31. Close panel
8.
Toggle store slice and probe
state in slide
33. Current slide page
9.
Toggle store playback state in
slide
10. Toggle store camera state in
slide
11. Toggle store panel layout
state in slide
26. Constrain camera to probe
(inverted)
27. Set panel contents to 3D view
32. Expand panel
34. Current slide
35. Current slice-manipulation
mode
36. Currently selected tab (Intracardiac structures page)
37. Unselected tab (right atrium)
12. Slide drop-down menu
38. Open-page drop-down menu
13. Previous slide
39. Show TEE control panel in the
3D view
14. Next slide
15. Delete current slide
40. Set panel contents to 3D view
16. Create new slide
41. Set panel contents to ultrasound view
17. Expand/collapse slice toolbar
42. Set panel contents to browser
18. Invert slice-plane
43. Split panel horizontally
19. Reset slice-plane
44. Close panel
20. Slice-manipulation mode
drop-down menu
45. Expand panel
21. Expand/collapse camera
toolbar
47. Scroll up
46. Close current page
22. Show/hide all structures
48. 3D view
23. Toggle visibility of selected
structure
24. Go to default camera view of
selected structure
49. Simulated ultrasound probe
50. Expand/collapse substructures
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51. Show/hide all structures
77. Close TEE control panel
52. Collapse list of substructures
53. Toggle structure visibility
78. Level of teeth when measuring probe depth
54. List of sub structures
79. Plane of ultrasound
55. Scroll bar
80. Ultrasound view
56. Go to default view of selected structure
81. Currently selected structure
57. Open section in anatomy
textbook pertaining to selected structure
83. Increase ultrasound plane rotation
58. Currently selected structure
85. Probe twist dial
59. Browser
60. Transparent section of heart
86. Decrease ultrasound plane rotation
61. Expand list of substructures
87. Probe flexion dial
62. Currently selected structure
88. Lock/unlock flexion
63. Vertical divider
89. 1cm markers
64. Horizontal divider
90. EKG/timeline
65. Decrease ultrasound penetration depth
91. Playhead (current phase of cardiac cycle)
66. Increase ultrasound penetration depth
92. Playback-speed slider
67. Set panel contents to 3D
view
82. Probe depth slider
84. Reset ultrasound plane rotation
93. Expand/collapse playbackspeed slider
94. Play/pause
68. Set panel contents to ultrasound view
95. Toggle EKG/timeline
69. Set panel contents to browser
97. Take screenshot
96. Close EKG panel
70. Vertically expand panel
71. Close panel
72. Scroll down
73. Licensee
74. Expand panel
75. Enable/disable mannequin
simulator
76. Rotation of simulated ultrasound plane
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