Superiority of Simulator-Based Training Compared With Conventional Training Methodologies in the Performance of Transseptal Catheterization

Current State of Simulation in Interventional Cardiology Training: Results of a SCAI Survey

Background

Interventional cardiology (IC) is well suited to simulation education, with a wide spectrum of digital and physical models for procedural training. Despite this, standardization, validation, and access to simulation training remains inconsistent in the United States and globally. Ten years have elapsed since the last Society for Cardiovascular Angiography & Interventions (SCAI) expert consensus statement on simulation in IC, which included a survey of US program directors. In this document, we report the results of a follow-up survey with the goal of broadening polling to all career stages, both in the US and internationally.

Methods

A web-based 19-item survey with embedded subquestions was sent out via email solicitation to SCAI members from September 2023 to December 2023.

Results

In total, 420 responses were collected, with a 15% response rate. Nearly 70% of respondents were from the US. There was equal distribution in responses for all stages of training, with most respondents performing coronary procedures. Two-thirds had previous exposure to simulation training with most using digital simulators and reporting only 1 to 2 days of exposure for each type or procedure. A majority (71%) felt that they had insufficient simulation training; most felt that simulation fidelity was average. The biggest barrier to simulation training was a lack of access.

Conclusions

Despite efforts to develop simulation in IC training, there remain gaps in accessibility, exposure, and curricula. Professional organizations, industry, and educational governing bodies must collaborate on specific, actionable strategies to enhance access to high-fidelity IC simulation training globally.

Digital health in cardiovascular medicine: An overview of key applications and clinical impact by the Portuguese Society of Cardiology Study Group on Digital Health

Digital health interventions including telehealth, mobile health, artificial intelligence, big data, robotics, extended reality, computational and high-fidelity bench simulations are an integral part of the path toward precision medicine. Current applications encompass risk factor modification, chronic disease management, clinical decision support, diagnostics interpretation, preprocedural planning, evidence generation, education, and training. Despite the acknowledged potential, their development and implementation have faced several challenges and constraints, meaning few digital health tools have reached daily clinical practice. As a result, the Portuguese Society of Cardiology Study Group on Digital Health set out to outline the main digital health applications, address some of the roadblocks hampering large-scale deployment, and discuss future directions in support of cardiovascular health at large.

Randomized Controlled Trial Comparing Training of Transseptal Puncture With or Without Intracardiac Echocardiography

BACKGROUND

Intracardiac echocardiography (ICE) has been widely used in the catheter ablation of atrial fibrillation (AF). However, the value of ICE in the training of transseptal puncture (TSP) is unclear.

METHODS

ICE-Training Study was a single-center, parallel-group, unmasked, randomized controlled trial registered in ChineseClinicalTrials.gov. Participants were randomly assigned (1:1) to different groups (1) the ICE simulator training group (ICE-ST), in which TSP was trained and performed under the guidance of both ICE and x-ray; and (2) the conventional simulator training group (Con-ST), in which TSP was trained and performed only under the guidance of x-ray. The trainees need to undergo the training stage and the evaluation stage.

RESULTS

From October 2022 to December 2022, 18 consecutive fellows (age 32.4 ± 4.4 years, 12 males) without experience of TSP were included. The training period (16.9 ± 6.6 vs. 29.6 ± 8.7 times, p = 0.003) and the fluoroscopy time (120.3 ± 25.3 vs. 189.3 ± 40.2 s, p < 0.001) of the ICE-ST group was significantly shorter than that of the Con-ST group. No significant difference was found in the comprehensive performance of TSP in the ICE-ST group (composite score 96.7 ± 5.7) and the Con-ST group (composite score 95.9 ± 6.3, p = 0.62), but the selection of TSP sites in the ICE-ST group was commonly better than that in the Con-ST group.

CONCLUSIONS

ICE could improve the efficiency of TSP training and optimize the site of TSP to facilitate catheter manipulation in the ablation.

TRIAL REGISTRATION

ChineseClinicalTrials.gov identifier: ChiCTR2200058377.

High-fidelity pose estimation for real-time extended reality (XR) visualization for cardiac catheterization

Extended reality (XR) technologies are emerging as promising platforms for medical training and procedural guidance, particularly in complex cardiac interventions. This paper presents a high-fidelity methodology to perform real-time 3D catheter tracking and visualization during simulated cardiac interventions. A custom 3D-printed setup with mounted cameras enables biplane video capture of a catheter. A computer vision algorithm processes the biplane images in real-time to reconstruct the 3D catheter trajectory represented by any designated number of points along its length. This method accurately localizes the catheter tip within 1 mm and can reconstruct any arbitrary catheter configuration. The tracked catheter data is integrated into an interactive Unity-based scene rendered on the Meta Quest 3 headset. The visualization seamlessly combines a reconstructed 3D patient-specific heart model with the dynamically tracked catheter, creating an immersive extended reality training environment. Our experimental study, involving six participants, demonstrated that the 3D visualization provided by the proposed XR system significantly outperformed 2D visualization in terms of speed and user experience. This suggests that the XR system has the potential to enhance catheterization training by improving spatial comprehension and procedural skills. The proposed system demonstrates the potential of XR technologies to transform percutaneous cardiac interventions through improved visualization and interactivity.

An anthropomorphic phantom for atrial transseptal puncture simulation training

BACKGROUND

Transseptal puncture (TSP) is a critical prerequisite for left-sided cardiac interventions, such as atrial fibrillation (AF) ablation and left atrial appendage closure. Despite its routine nature, TSP can be technically demanding and carries a risk of complications. This study presents a novel, patient-specific, anthropomorphic phantom for TSP simulation training that can be used with X-ray fluoroscopy and ultrasound imaging.

METHODS

The TSP phantom was developed using additive manufacturing techniques and features a replaceable fossa ovalis (FO) component to allow for multiple punctures without replacing the entire model. Four cardiologists and one cardiology trainee performed TSP on the simulator, and their performance was assessed using four metrics: global isotropy index, distance from the centroid, time taken to perform TSP, and a set of 5-point Likert scale questions to evaluate the clinicians' perception of the phantom's realism and utility.

RESULTS

The results demonstrate the simulator's potential as a training tool for interventional cardiology, providing a realistic and controllable environment for clinicians to refine their TSP skills. Experienced cardiologists tended to cluster their puncture points closer to regions of the FO associated with higher global isotropy index scores, indicating a relationship between experience and optimal puncture localization. The questionnaire analysis revealed that participants generally agreed on the phantom's realistic anatomical representation and ability to accurately visualize the TSP site under fluoroscopic guidance.

CONCLUSIONS

The TSP simulator can be incorporated into training programs, offering trainees the opportunity to improve tool handling, spatial coordination, and manual dexterity prior to performing the procedure on patients. Further studies with larger sample sizes and longitudinal assessments are needed to establish the simulator's impact on TSP performance and patient outcomes.

Impact of resident training on cardiac electrophysiological procedures

BACKGROUND

Modern management of cardiac arrhythmias often requires interventions in which young physicians must acquire a high level of expertise. However, concerns have been raised about the increase in side effects during procedures performed with resident involvement.

AIM

This study aims to identify the effects of resident training on cardiac electrophysiological procedures within a university centre.

METHODS

In a single-centre study, cardiac arrhythmia procedures were reviewed retrospectively, and resident involvement was scrutinized. Univariate and multivariable models were built for the following outcomes: fluoroscopy time; operative time; length of hospitalization after procedure; and adverse events.

RESULTS

We reviewed 991 procedures, 574 without and 417 with resident involvement (650 cardiac pacemakers or defibrillators, 120 generator replacements, 188 electrophysiological studies and 153 radiofrequency ablations). Resident involvement was associated with an increase in fluoroscopy time: +1.7±0.4minutes (P<0.01) for pacemaker implantation; and +2.5±0.9minutes (P=0.01) for electrophysiological studies. Operative time was longer for electrophysiological studies (+10.8±4.9minutes; P=0.03) and pacing implantation (+8.4±2.2minutes; P<0.01). There was no significant association between resident training and adverse events (7.67 vs. 9.83%; P=0.28).

CONCLUSIONS

Cardiac electrophysiological procedures performed with resident involvement have a good safety profile. However, resident training modestly, but significantly, prolongs fluoroscopy time and operative time.

The Impact of Simulation-Based Training in Cardiovascular Medicine: A Systematic Review

Cardiovascular medicine and practice in recent times have evolved as complex procedures are performed to manage difficult cases. The majority of these interventions are done percutaneously in order to minimize patient risk. Additionally, training specialist in handling these interventions require a lot of exposure to them; as such, patients are at higher risk of errors and complications from trainees before attaining expertise. In order to avoid these possible risks to patients and ensure their safety, using simulation commonly in cardiovascular specialist education is a possible trend in the future. This article aims to review randomized controlled trials that were performed in cardiology and vascular medicine regarding the use of simulating models to transfer skills to trainees. This study is a systematic review that includes publications dated from 2010 from any country and only in English. The search involved several combinations of search terms from medical subject headings (MeSH). Keywords in the title, abstract, and text for the population, intervention, control, and outcomes were first done in a pilot search to establish the sensitivity of the search strategy. Studies were searched in PubMed, Medline, Cochrane Library, Embase, CINAHL, and Hirani. Data were presented in the PRISMA flowchart and tabular form. A total of 389 studies were obtained from five databases using the search strategies. Eighty-nine studies were excluded for duplication. The total number of studies that did not meet the inclusion criteria was 269, and they were excluded based on abstract and title screening. Another 18 studies were excluded based on full-text screening. In this study, 13 articles were selected ranging from 2011 to 2022. The majority of the outcomes of the study demonstrated that simulation tutoring complements traditional methods of training. Countries of publication were the United States of America, Canada, Italy, Korea, California, Ireland, Germany, Belgium, Switzerland, United Kingdom, Netherlands, and France. Procedures simulated include coronary angiography, transseptal catheterization, cardiopulmonary resuscitation, ultrasound-guided radial artery cannulation, diagnostic angiograms, coiled carotid terminus aneurysms in the setting of subarachnoid hemorrhage, middle cerebral artery embolectomies, renal artery angioplasty/stenting, endovascular aneurysm repair, transvenous pacing wire, intra-aortic balloon pump, and pericardiocentesis. Despite the accredited drawback of availability and cost noted with simulation-based education, there is evidence that it offers many advantages compared to traditional teaching methods. From this study, simulation-based teaching has been shown to effectively transfer skills to trainees especially when used as an adjunct to the apprenticeship method. As a result, we recommend that virtual reality education should be integrated with real-life teaching in modern cardiovascular modules as this will help ensure early skill transfer while maintaining patient safety.

Simulation-Based Education in Acute and Chronic Pain Training

PURPOSE OF REVIEW

The use of simulation-based education (SBE) in medical training has expanded greatly and has grown to include high fidelity and task simulation along with hybrid models using patient actors to enhance education and training of critical events as well as technical skills.

RECENT FINDINGS

In the field of anesthesiology, SBE has been particularly useful for crisis resource management and rare critical scenarios and new research into the use of SBE using task simulation for procedural skill development has been done highlighting the benefits to subspecialty procedural training. Medical simulation has become a common practice in medical training and research. SBE has demonstrated positive outcomes in improving technical skills, knowledge, comfort, and clinical performance. The widespread implementation of SBE in regional anesthesia and chronic pain training varies, with cost and availability being factors. Nonetheless, SBE has shown great potential in enhancing education and preparing physicians in subspecialties of anesthesia.

Design and Validation of a Soft Robotic Simulator for Transseptal Puncture Training

OBJECTIVE

Transseptal puncture (TP) is the technique used to access the left atrium of the heart from the right atrium during cardiac catheterization procedures. Through repetition, electrophysiologists and interventional cardiologists experienced in TP develop manual skills to navigate the transseptal catheter assembly to their target on the fossa ovalis (FO). Cardiology fellows and cardiologists that are new to TP currently train on patients to develop this skill, resulting in increased risk of complications. The goal of this work was to create low-risk training opportunities for new TP operators.

METHODS

We developed a Soft Active Transseptal Puncture Simulator (SATPS), designed to match the dynamics, static response, and visualization of the heart during TP. The SATPS includes three subsystems: (i) A soft robotic right atrium with pneumatic actuators mimics the dynamics of a beating heart. (ii) A fossa ovalis insert simulates cardiac tissue properties. (iii) A simulated intracardiac echocardiography environment provides live visual feedback. Subsystem performance was verified with benchtop tests. Face and content validity were evaluated by experienced clinicians.

RESULTS

Subsystems accurately represented atrial volume displacement, tenting and puncture force, and FO deformation. Passive and active actuation states were deemed suitable for simulating different cardiac conditions. Participants rated the SATPS as realistic and useful for training cardiology fellows in TP.

CONCLUSION

The SATPS can help improve catheterization skills of novice TP operators.

SIGNIFICANCE

The SATPS could provide novice TP operators the opportunity to improve their TP skills before operating on a patient for the first time, reducing the likelihood of complications.

The perceived value and impact of virtual simulation-based education on students' learning: a mixed methods study

BACKGROUND

Virtual simulations are used throughout healthcare training programs to enable development of clinical skills, however the potential for virtual simulation to enhance cognitive and affective skills is less well understood. This study explored pre-clinical optometry students' perceptions of the impact of virtual simulation on the development of core competency skills including patient-centred care, communication, scientific literacy, and evidence-based practice.

METHODS

A mixed methods study was conducted using pre-existing anonymized data from an electronic survey distributed to pre-clinical optometry students enrolled in the double degree Bachelor of Vision Science/Master of Optometry at Deakin University, Australia. The data were interpreted using descriptive statistics and qualitative analysis using constant comparison for thematic analysis.

RESULTS

A total of 51 responses were analyzed. Students reported that virtual simulation motivated them to become an optometrist (93%) and to learn beyond the course material (77%). Students reported that after participating in the virtual simulation, their core competency skills improved: patient-centered care (100%) evidence-based practice (93%) and clinical reasoning (93%). The themes identified through qualitative analysis were: enablers to cognitive experience in virtual simulation in optometry education, realism of the virtual simulation design, dimensions of fidelity in virtual simulations design replicated the complexity of the optometric environment, virtual simulation as an enabler for learning and assessment in optometry education, a place to develop cognitive and affective skills and application of learning in the virtual simulation developed an appreciation of future roles and professional identity.

CONCLUSION

Optometry students perceived virtual simulation in optometric education as a valuable training and assessment strategy enabled by qualities that generate contextual, cognitive, functional, task and psychological fidelity. The data provide insight to inform how optometry educators can incorporate simulation into the curriculum.

A randomized controlled trial of simulation training in teaching coronary angiographic views

INTRODUCTION

Simulation technology has an established role in teaching technical skills to cardiology fellows, but its impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training, in addition to traditional methods would improve CA image interpretation skills in a heterogeneous group of medical trainees.

METHODS

We prospectively randomized a convenience sample of 105 subjects comprising of medical students (N = 20), residents (N = 68) and fellows (N = 17) from the University of Arizona. Subjects were randomized in a stratified fashion into a simulation training group which received simulation training in addition to didactic teaching (n = 53) and a control training group which received didactic teaching alone (n = 52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm.

RESULTS

Subjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p = 0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p = 0.02 for interaction of training arm and education status.

CONCLUSIONS

Simulation training complements traditional methods to improve CA interpretation skill, with greatest impact on residents. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

A Skill Trainer for Balloon/Stent Exchange in Percutaneous Coronary Intervention-Concept and Evaluation

BACKGROUND

To prevent complications, uncontrolled movement of the guidewire during a coronary intervention should be avoided. Unintentional withdrawal of the wire can result in the inability to recross a lesion with the risk of myocardial infarction. On the other hand, unintended forward pushing can lead to a coronary perforation. Thus, interventionalists in training should practice keeping the coronary guidewire in a stable position to prevent complications. For this purpose, a skill trainer has been developed, which provides the possibility of unlimited practice outside of the cath lab.The purpose of this study was to assess the effectiveness and the validity of this skills trainer.

METHODS

Ten novices and 10 participants with experience in diagnostic catheterization underwent training on the skills trainer consisting of 25 procedures. To assess the efficacy of the training module, the mean score of the first 3 procedures was compared with the final 3 procedures in the novice and the advanced group. To determine the construct validity of the simulator, a group of experts (E; performed >1000 percutaneous coronary interventions) also underwent evaluation on the skills trainer. For each procedure, the change in position of the guidewire as well as the time was determined and combined into a skills score with a maximum of 15 points.

RESULTS

The novice and the advanced group improved significantly throughout the training on the simulator (N: 7.1 ± 2.6 to 12.2 ± 2.0, P = 0.007; A: 8.3 ± 2.0 to 13.2 ± 1.0, P = 0.005, Wilcoxon).The experts scored significantly higher than novices or the advanced participants during their first 3 procedures (E: 12.9 ± 1.0; N: 7.1 ± 2.6, P = 0.001; A: 8.3 ± 2.0, P = 0.001; Mann-Whitney U ).

CONCLUSIONS

This low-cost task trainer is a valid and effective tool to train adequate balloon/stent exchange while keeping the guidewire in a stable position. Whether the skills acquired on the task trainer can be transferred to procedures performed on patients needs further investigation.

Step, Error, and Event Frameworks in Endovascular Aortic Repair

OBJECTIVE

Competency-based surgical education requires detailed and actionable feedback to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (ORBB; Surgical Safety Technologies, Inc), which continuously records and synchronizes multiple sources of intraoperative data, have recently been integrated into hybrid rooms to provide targeted feedback to endovascular teams. The objective of this study is to develop step, error, and event frameworks to evaluate technical performance in elective endovascular aortic repair (EVAR) comprehensively captured by the ORBB (Surgical Safety Technologies, Inc; Toronto, Canada).

METHODS

This study is based upon a modified Delphi consensus process to create evaluation frameworks for steps, errors, and events in EVAR. International experts from Vascular Surgery and Interventional Radiology were identified, based on their records of publications and invited presentations, or serving on relevant journal editorial boards. In an initial open-ended survey round, experts were asked to volunteer a comprehensive list of steps, errors, and events for a standard EVAR of an infrarenal aorto-iliac aneurysm (AAA). In subsequent survey rounds, the identified items were presented to the expert panel to rate on a 5-point Likert scale. Delphi survey rounds were repeated until the process reached consensus with a predefined agreement threshold (Cronbach α>0.7). The final frameworks were constructed with items achieving an agreement (responses of 4 or 5) from greater than 70% of experts.

RESULTS

Of 98 invited proceduralists, 38 formed the expert consensus panel (39%), consisting of 29 vascular surgeons and 9 interventional radiologists, with 34% from North America and 66% from Europe. Consensus criteria were met following the third round of the Delphi consensus process (Cronbach α=0.82-0.93). There were 15, 32, and 25 items in the error, step, and event frameworks, respectively (within-item agreement=74%-100%).

CONCLUSION

A detailed evaluation tool for the procedural steps, errors, and events in infrarenal EVAR was developed. This tool will be validated on recorded procedures in future work: It may focus skill development on common errors and hazardous steps. This tool might be used to provide high-quality feedback on technical performance of trainees and experienced surgeons alike, thus promoting surgical mastery.

Virtual Clinical Encounter Examination (VICEE): A novel approach for assessing medical students' non-psychomotor clinical competency

INTRODUCTION

The Corona Virus Disease-19 (COVID-19) pandemic disrupted medical education across the world. Online teaching has grown rapidly under lockdown. Yet the online approach for assessment presents a number of challenges, particularly when evaluating clinical competencies. The aim of this study was to investigate the feasibility, acceptability, reliability and validity of an online Virtual Clinical Encounter Examination (VICEE) to assess non-psychomotor competencies (non-procedure or manual skills) of medical students.

METHOD

Sixty-one final year medical students took the VICEE as part of the final summative examination. A panel of faculty experts developed the exam cases and competencies. They administered the test online via real-time interaction with artificial intelligence (AI) based virtual patients, along with faculty and IT support.

RESULTS

Student and faculty surveys demonstrated satisfaction with the experience. Confirmatory factor analysis supported convergent validity of VICEE with Direct Observation Clinical Encounter Examination (DOCEE), a previously validated clinical examination. The observed sensitivity was 81.8%, specificity 64.1% and likelihood ratio 12.6, supporting the ability of VICEE to diagnose 'clinical incompetence' among students.

CONCLUSION

Our results suggest that online AI-based virtual patient high fidelity simulation may be used as an alternative tool to assess some aspects of non-psychometric competencies.

Simulation-based training in cardiology: State-of-the-art review from the French Commission of Simulation Teaching (Commission d'enseignement par simulation-COMSI) of the French Society of Cardiology

In our healthcare system, mindful of patient safety and the reduction of medical errors, simulation-based training has emerged as the cornerstone of medical education, allowing quality training in complete safety for patients. Initiated by anaesthesiologists, this teaching mode effectively allows a gradual transfer of learning, and has become an essential tool in cardiology teaching. Cardiologists are embracing simulation to master complex techniques in interventional cardiology, to manage crisis situations and unusual complications and to develop medical teamwork. Simulation methods in cardiology include high-fidelity simulators, clinical scenarios, serious games, hybrid simulation and virtual reality. Simulation involves all fields of cardiology: transoesophageal echocardiography, cardiac catheterization, coronary angioplasty and electrophysiology. Beyond purely technical issues, simulation can also enhance communication skills, by using standardized patients, and can improve the management of situations related to the announcement of serious diseases. In this review of recent literature, we present existing simulation modalities, their applications in different fields of cardiology and their advantages and limitations. Finally, we detail the growing role for simulation in the teaching of medical students following the recent legal obligation to use simulation to evaluate medical students in France.

Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students' perception

BACKGROUND

The Coronavirus Disease 19 (COVID-19) pandemic brought significant disruption to in-hospital medical training. Virtual reality simulating the clinical environment has the potential to overcome this issue and can be particularly useful to supplement the traditional in-hospital medical training during the COVID-19 pandemic, when hospital access is banned for medical students. The aim of this study was to assess medical students' perception on fully online training including simulated clinical scenarios during COVID-19 pandemic.

METHODS

From May to July 2020 when in-hospital training was not possible, 122 students attending the sixth year of the course of Medicine and Surgery underwent online training sessions including an online platform with simulated clinical scenarios (Body Interact™) of 21 patient-based cases. Each session focused on one case, lasted 2 h and was divided into three different parts: introduction, virtual patient-based training, and debriefing. In the same period, adjunctive online training with formal presentation and discussion of clinical cases was also given. At the completion of training, a survey was performed, and students filled in a 12-item anonymous questionnaire on a voluntary basis to rate the training quality. Results were reported as percentages or with numeric ratings from 1 to 4. Due to the study design, no sample size was calculated.

RESULTS

One hundred and fifteen students (94%) completed the questionnaire: 104 (90%) gave positive evaluation to virtual reality training and 107 (93%) appreciated the format in which online training was structured. The majority of participants considered the platform of virtual reality training realistic for the initial clinical assessment (77%), diagnostic activity (94%), and treatment options (81%). Furthermore, 97 (84%) considered the future use of this virtual reality training useful in addition to the apprenticeship at patient's bedside. Finally, 32 (28%) participants found the online access difficult due to technical issues.

CONCLUSIONS

During the COVID-19 pandemic, online medical training including simulated clinical scenarios avoided training interruption and the majority of participant students gave a positive response on the perceived quality of this training modality. During this time frame, a non-negligible proportion of students experienced difficulties in online access to this virtual reality platform.

Simulation Training in Neuroangiography: Transfer to Reality

PURPOSE

Endovascular simulation is an established and validated training method, but there is still no proof of direct patient's benefit, defined as lower complication rate. In this study, the impact of such a training was investigated for rehearsal of patient-specific cases as well as for a structured simulation curriculum to teach angiographer novices.

MATERIALS AND METHODS

A total of 40 patients undergoing a diagnostic neuroangiography were randomized in a training and control group. In all training group patients, the angiographer received a patient-anatomy-specific rehearsal on a high-fidelity simulator prior to the real angiography. Radiation exposure, total duration, fluoroscopy time and amount of contrast agent of the real angiography were recorded. Silent cerebral ischemia was counted by magnetic resonance diffusion-weighted imaging (DWI). Additionally, the first 30 diagnostic neuroangiographies of six novices were compared (n_total = 180). Three novices had undergone a structured simulation curriculum; three had acquired angiographic skills without simulation.

RESULTS

No differences were found in the number of DWI lesions or in other quality measures of the angiographies performed with and without patient-specific rehearsal. A structured simulation curriculum for angiographer novices reduced fluoroscopy time significantly and radiation exposure. The curriculum had no influence on the total duration of the examination, the amount of contrast medium or the number of catheters used.

CONCLUSION

There was no measurable benefit of patient-anatomy-specific rehearsal for an unselected patient cohort. A structured simulation-based curriculum to teach angiographic skills resulted in a reduction of fluoroscopy time and radiation dose in the first real angiographies of novice angiographers.

LEVEL OF EVIDENCE

Level 4, part 1: randomized trial, part 2: historically controlled study.

Training in Interventional Radiology: A Simulation-Based Approach

Innovations in medical technology have revolutionised both medical and surgical practice. Indeed, with such innovations, training for specific specialties has become more advanced and streamlined. However, despite these novel approaches to train students and specialist trainees, training for interventional radiology (IR) is lagging. While the reason for this lag remains contentious, one of the primary reasons for this issue may be the lack of standardisation for IR training due to a scarcity of specific guidelines for the delivery of IR procedural training. Interventional radiologists manage a vast array of conditions and perform various procedures. However, training for each procedure is largely dependent on the centre and access to a range of cases. Recently, the use of simulation technology has allowed this issue to be addressed. Simulation technology allows trainees to participate in a range of procedures regardless of their centre and availability of cases. Specialties such as cardiology and vascular surgery have already adopted simulation-based technology for trainees and have commented positively on this approach. However, simulation-based training is still lacking in the IR training pathway. Here, we evaluate why IR training can benefit from a more simulation-based approach. We further consider the cost-effectiveness of implementing simulation-based training nationally. Finally, we outline the potential pitfalls that may arise of introducing simulation-based training for IR trainees. We conclude that despite its disadvantages, simulation training will prove to be more cost-efficient and allow standardisation of IR training.

A New Educational Framework to Improve Lifelong Learning for Cardiologists

Lifelong learning is essential for the practicing cardiologist. Present lifelong learning mechanisms are stagnant and at risk for not meeting the needs of currently practicing cardiologists. With the increasing burden of cardiovascular disease, growing complexity of patient care, and ongoing pressures of nonclinical responsibilities, educational programming must evolve to meet the demands of the contemporary cardiovascular professional. A paradigm shift, replete with modern and practical educational tools, is needed in the lifelong learning armamentarium. Emerging evidence of novel educational strategies in graduate medical education supports the promise of broader application of these tools to different stages of professional life. In this commentary from the Fellows-in-Training Section Leadership Council, the authors propose 3 novel educational tools-personalized learning, adaptive learning, and the flipped classroom-to improve lifelong learning to meet the educational needs of fellows-in-training to practicing cardiologists alike.

Development of simulation combining a physical heart model and three-dimensional system for electrophysiology training

BACKGROUND

A new three-dimensional heart anatomical simulator (3D HAS) has been created combining a physical heart model with an electroanatomic mapping (EAM) system. The aim of this study is to describe the development and the validation process of this device.

METHODS

We developed the 3D HAS combining a physical heart model with an EAM system. This simulator was then validated by 10 electrophysiologists, subdivided in two groups based on their experience in electrophysiology procedures. The performance of the experts was compared to the one of the novices in achieving three different tasks: fluoroless reconstruction of the right atrium, coronary sinus cannulation, and deployment of a linear ablation lesion in the cavotricuspid isthmus. For each operator, a score was calculated based on objective parameter for each task and for the overall performance.

RESULTS

The 3D HAS was located in an environment that allowed use of the main features of the EAM system including contact force sensing. No technical issue was encountered during the validation process. The experts' performance was significantly better than the one of the novices both overall (P = 0.009) and in each task (right atrium reconstruction, P = 0.016; coronary sinus cannulation, P = 0.008; ablation lesion, P = 0.03).

CONCLUSIONS

The 3D HAS is reliable and allows use of the main features of an EAM system in the right atrium. The ability to discriminate different levels of experience suggests that this simulator is enough realistic and could be useful for electrophysiology training.

Effectiveness of echocardiography simulation training for paediatric cardiology fellows in CHD

Simulation is used in many aspects of medical training but less so for echocardiography instruction in paediatric cardiology. We report our experience with the introduction of simulator-based echocardiography training at Weill Cornell Medicine for paediatric cardiology fellows of the New York-Presbyterian Hospital of Columbia University and Weill Cornell Medicine. Knowledge of CHD and echocardiographic performance improved following simulation-based training. Simulator training in echocardiography can be an effective addition to standard training for paediatric cardiology trainees.

Initial experience with a novel electrophysiology mapping simulator

BACKGROUND

Despite data supporting the use of simulation training in procedural specialties and accreditation requirements, few options exist for electrophysiology (EP) training. We aimed to develop a low-cost, accessible simulator for training in EP mapping, and to test the simulator in a group of novice users.

METHODS

Our mapping simulator is composed of three components: an acrylic case representing torso and thigh; three-dimensional (3D) printed cardiac models; and a commercially available mapping system. Using a proprietary flexible material that mimics the consistency of human heart tissue, we created an anatomically accurate model of a normal right atrium (RA) from computed tomography data. We developed a test protocol consisting of two activities: creation of a RA shell and timed navigation to specific locations within the RA shell. Seventeen participants were randomized to either practice versus no practice on the simulator, and repeated simulator and self-assessment tests were performed after 1 week. We measured volume of the RA map and time taken and distance from the target sites for each target location.

RESULTS

Both groups showed improvement in generation of geometry, volume, time to target, and self-assessed comfort level after initial exposure to the simulator. Compared with no-practice, the practice group demonstrated an improved sense of confidence in mapping.

CONCLUSIONS

Focused training in EP mapping using a novel simulator created with 3D printed heart models and a standard mapping system is feasible for use in the training environment. Exposure to the simulator is associated with improved mapping skills and trainee comfort level.

Effects of Advanced Cardiac Procedure Simulator Training on Learning and Performance in Cardiovascular Medicine Fellows

BACKGROUND

Simulation-based training has been used in medical training environments to facilitate the learning of surgical and minimally invasive techniques. We hypothesized that integration of a procedural simulation curriculum into a cardiology fellowship program may be educationally beneficial.

METHODS

We conducted an 18-month prospective study of cardiology trainees at Vanderbilt University Medical Center. Two consecutive classes of first-year fellows (n = 17) underwent a teaching protocol facilitated by simulated cases and equipment. We performed knowledge and skills evaluations for 3 procedures (transvenous pacing [TVP] wire, intra-aortic balloon pump [IABP], and pericardiocentesis [PC]). The index class of fellows was reevaluated at 18 months postintervention to measure retention. Using nonparametric statistical tests, we compared assessments of the intervention group, at the time of intervention and 18 months, with those of third-year fellows (n = 7) who did not receive simulator-based training.

RESULTS

Compared with controls, the intervention cohort had higher scores on the postsimulator written assessment, TVP skills assessment, and IABP skills assessment (P = .04, .007, and .02, respectively). However, there was no statistically significant difference in scores on the PC skills assessment between intervention and control groups (P = .08). Skills assessment scores for the intervention group remained higher than the controls at 18 months (P = .01, .004, and .002 for TVP, IABP, and PC, respectively). Participation rate was 100% (24/24).

CONCLUSIONS

Procedural simulation training may be an effective tool to enhance the acquisition of knowledge and technical skills for cardiology trainees. Future studies may address methods to improve performance retention over time.

Transseptal Techniques for Emerging Structural Heart Interventions

The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.

Development and Validation of a Teaching Module for Echocardiographic Scoring of Rheumatic Mitral Stenosis

BACKGROUND

The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application-both in the United States where the incidence of rheumatic heart disease has fallen and in rheumatic heart disease endemic countries where training infrastructure is weak.

OBJECTIVES

This study sought to develop a computer-based educational module teaching 2 scoring systems for rheumatic mitral stenosis and to validate the module among cardiology fellows in the United States and Uganda.

METHODS

We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from 2 academic centers in the United States and 1 in Uganda. Subject answers were compared with a score assigned by 2 experts in echocardiography. The primary outcome was change in subjects' accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3.

RESULTS

The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0 to 16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0 to 4). The change from set 1 to set 3 was statistically significant only for 1 of the Wilkins component scores (leaflet calcification, p < 0.001.) No change was seen in the interoperator variability. Individual subject bias in assigning the total Wilkins score was reduced from set 1 to set 3.

CONCLUSIONS

Use of this module has the potential to enhance the training of cardiologists in the echocardiographic assessment of mitral stenosis. Modified versions of this module or similar ones should be tested in targeted populations of cardiology trainees with the most exposure to mitral stenosis interventions.

Prospective, randomised and blinded comparison of proficiency-based progression full-physics virtual reality simulator training versus invasive vascular experience for learning carotid artery angiography by very experienced operators

Introduction

We assessed the transfer of training (ToT) of virtual reality simulation training compared to invasive vascular experience training for carotid artery angiography (CA) for highly experienced interventionists but new to carotid procedures.

Methods

Prospective, randomised and blinded.

Setting

Catheterisation and skills laboratories in the USA.

Participants

Experienced (mean volume=15 000 cases) interventional cardiologists (n=12) were randomised to train on virtual reality (VR) simulation to a quantitatively defined level of proficiency or to a traditional supervised in vivo patient case training.

Outcome measures

The observed performance differences in performing a CA between two matched groups were then blindly assessed using predefined metrics of performance.

Results

Experienced interventional cardiologists trained on the VR simulator performed significantly better than their equally experienced controls showing a significantly lower rate of objectively assessed intraoperative errors in CA. Performance showed 17–49% ToT from the VR to the in vivo index case.

Discussion

This is the first prospective, randomised and blinded clinical study to report that VR simulation training transfers improved procedural skills to clinical performance on live patients for experienced interventionists. This study, for the first time, demonstrates that VR simulation offers a powerful, safe and effective platform for training interventional skills for highly experienced interventionists with the greatest impact on procedural error reduction.

Simulator Training in Interventional Cardiology

Simulator training in interventional cardiology is becoming a central part of early career acquisition of technical and non-technical skills. Its use is now mandated by national training organisations. Haptic simulators, part-task trainers, immersive environments and simulated patients can provide benchmarked, reproducible and safe opportunities for trainees to develop without exposing patients to the learning curve. However, whilst enthusiasm persists and trainee-centred evidence has been encouraging, simulation does not yet have a clear link to improved clinical outcomes. In this article we describe the range of simulation options, review the evidence for their efficacy in training and discuss the delivery of training in technical skills as well as human factor training and crisis resource management. We also review the future direction and barriers to the progression of simulation training.

Evidence for Endovascular Simulation Training: A Systematic Review

BACKGROUND

Simulation training in endovascular surgery provides opportunities for trainees to practice and learn from non-patient based experience. Several types of endovascular simulators are available commercially. Previous studies on endovascular simulation training can be categorized into trials in which only a simulator was used when measuring performance metrics or "trials within simulation"; patient specific procedure rehearsals; and randomized, controlled trials (RCTs) or translational studies.

OBJECTIVES

To examine whether endovascular simulation training can improve surgeon techniques and patient outcomes in real clinical settings.

METHODS

A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed and Embase. Review articles, and papers that were not related to endovascular surgery and not within the scope of interest were excluded. References of review articles were further screened according to the exclusion criteria.

RESULTS

In total, 909 records were identified and 290 duplicates were removed. Thirty-one were included in the qualitative analysis. Twenty-three were trials within simulation and most of them found statistically significant improvements in procedure time, fluoroscopy time, and contrast volume. Five were patient specific procedure rehearsals and showed that simulation significantly affected the fluoroscopy angle and improved performance metrics. Three were RCTs and revealed mainly positive results on a Global Rating Scale and procedure specific rating scale.

CONCLUSIONS

Contemporary evidence shows that performance metrics within endovascular simulations improve with simulation training. Successful translation to in vivo situations is observed in patient specific procedure rehearsals and RCTs on real procedures. However, there is no level I evidence to show that predictive validity of simulation can definitively improve patient outcomes. Current literature supports the idea that there is a beneficial role of simulation in endovascular training. Future studies are needed to confirm the efficacy of simulation in endovascular surgical training and to see if simulation is superior to traditional training in the operating theatre.

Electroanatomic mapping systems (CARTO/EnSite NavX) vs. conventional mapping for ablation procedures in a training program

BACKGROUND

Three-dimensional electroanatomic mapping (EAM) systems reduce radiation exposure when radio frequency catheter ablation (RFCA) procedures are performed by well-trained senior operators. Given the steep learning curve associated with complex RFCA, trainees and their mentors must rely on multiple imaging modalities to maximize safety and success, which might increase procedure and fluoroscopy times. The objective of the present study is to determine if 3-D EAM (CARTO and ESI-NavX) improves procedural outcomes (fluoroscopy time, radio frequency time, procedure duration, complication, and success rates) during CA procedures as compared to fluoroscopically guided conventional mapping alone in an academic teaching hospital.

METHODS

We analyzed a total of 1070 consecutive RFCA procedures over an 8-year period for fluoroscopic time stratified by ablation target and mapping system. Multivariate logistic regression and adjusted odds ratios were calculated for each variable.

RESULTS

No statistically significant differences in acute success rates were noted between conventional and 3-D mapping cases [CARTO (p = 0.68) or ESI-NavX (p = 0.20)]. Moreover, complication rates were also not significantly different between CARTO (p = 0.23) and ESI-NavX (p = 0.53) when compared to conventional mapping. Procedure, radio frequency, and fluoroscopy times were significantly longer with CARTO and ESI-NavX versus conventional mapping [fluoroscopy time: CARTO, 28.3 min; ESI, 28.5 min; and conventional, 24.3 min; p < 0.001)].

CONCLUSIONS

The use of 3-D EAM systems during teaching cases significantly increases radiation exposure when compared with conventional mapping. These findings suggest a need to develop alternative training strategies that enhance confidence and safety during catheter manipulation and allow for reduced fluoroscopy and procedure times during RFCA.