# An Immersive Virtual Reality Simulator for Echocardiography Examination
## 1 Introduction
[26] conducted a study with 69 nursing students, where they learned the skill of placing a nasogastric tube using either traditional teaching methods or an AR-based anatomy simulation module. Through a survey, it was confirmed that learning with the AR-based module was more beneficial than traditional teaching methods. [PERSON] et al. [27] confirmed that AR technology-based surgical guidance improved the precision of pilot hole drilling for pedicle screws and enhanced surgical competency in a novice physician group. [PERSON] et al. [28] utilized an AR-based surgical guidance system for catheter insertion and hematoma removal during hypertensive intracerebral hemorrhage surgery, confirming its high accuracy and feasibility. [PERSON] et al. [29] developed advanced cardiovascular life support simulation scenarios and validated the effectiveness of communication skills during scenarios when cardiac arrest occurred using AR headsets. The validation was confirmed through interviews with 18 medical assistant students. [PERSON] et al. [30] compared the efficiency of a system guiding implant placement using augmented reality in dental implant surgery with traditional implant placement methods (the freehand method and template-based static placement). Many medical education institutions and hospitals are developing and utilizing virtual reality- or augmented reality-based clinical practice tools for training in various medical fields. However, research on the development of virtual reality- or augmented reality-based simulators for echocardiography training is still relatively scarce. Echocardiography is a diagnostic medical test that utilizes ultrasound technology to visualize the structure and function of the cardiac muscle. It involves creating images of the cardiac muscle to diagnose various cardiac conditions. This type of examination aids in the early detection and diagnosis of various cardiac issues, providing valuable support for treatment and management decisions. Echocardiography allows for the identification of various conditions such as hypertension, myocardial infarction, valvular cardiac disease, myocardial hypertrophy, abnormalities in ventricular cells and valves, cardiac failure, atrial fibrillation, and aneurysms. To accurately assess the cardiac condition of individuals undergoing such diverse examinations, it is essential to have precise probe contact at the correct locations, obtain appropriate echocardiographic images, and possess the ability to interpret the acquired ultrasound images. To enhance echocardiography skills, repetitive practice of echocardiographic examinations is essential, complementing theoretical learning. However, existing echocardiography practice faces challenges in skill improvement due to a lack of practice opportunities caused by insufficient practice equipment, inadequate adaptation to real clinical environments due to the technical limitations of equipment, difficulties in interaction with actual patients due to practicing in consistent scenarios, and discrepancies with real clinical environments. Therefore, similar to other medical practices, there is a high demand for virtual reality- or augmented reality-based practice tools in echocardiography training. Research on virtual or augmented reality-based simulators for echocardiography training has only been investigated in the study by [PERSON] et al. [16]. However, in this study, the virtual space for cardiac ultrasound examination was found to be simple, leading to a lack of immersion, and the use of only controllers for interaction made it difficult to provide learners with various sensations, resulting in a lack of realism. Additionally, it lacks multi-user connectivity, making it challenging for group education, collaborative practice, and real-time feedback within the virtual space. The objective of this paper is to develop a VR-based simulator that allows multi-user access, supports various interactive devices, and enables the practice of echocardiography examinations in diverse cardiac scenarios.