User Manual - Inventive Medical

Transcript

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 1 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 2 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 3 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 4 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. 5 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 6 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. 10 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. 18 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. 22 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). 23 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. 25 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 26 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). 32 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. 42 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). 48 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. 51 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 60 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. 61 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). 63 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). 64 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. 65 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 66 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. 67 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. 68 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. 69 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. 70 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. 71 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. 72 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. 73 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). 74 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. 75 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 76 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. 77 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 82 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 83