Telesimulation Training for Endoscopic Mitral Valve Surgery: An Air-Pilot Training Concept for Distance Training

OBJECTIVE

The aim of this study was to validate and assess the feasibility and impact of telesimulation training on surgical skills using a portable mitral valve telesimulator.

METHODS

A telesimulation course composed of 3 online modules was designed based on backwards chaining, preassessment and postassessment, performance feedback, hands-on training on a telesimulator, and the theoretical content. A fully 3-dimensional-printed and transportable telesimulator was developed and sent out to the participants with instruments that were needed. Feedback about the platform was obtained from participants to validate its value as a training tool. Theoretical and technical assessments were carried out before and after the course. Technical assessments were based on the accuracy and time taken to place sutures at the anterior and posterior mitral annulus.

RESULTS

In total, 11 practicing cardiac surgeons from Oceania, Asia, Europe, and North America completed the course. Theoretical preassessment and postassessment showed that participants scored significantly higher on postassessment (mean 87.5% vs 68.1%, P < 0.004). The participant evaluation scores of the simulator as a tool for endoscopic mitral valve surgery was 4 to 5 out of 5. There was a significant improvement in the speed (median 14.5 vs 39.5 s, P < 0.005) and the accuracy to place sutures in the mitral valve annulus following course completion (P < 0.001).

CONCLUSIONS

Here we validated the educational value of a novel telesimulation platform and validated the feasibility to teach participants at a distance the knowledge and skills for endoscopic mitral valve surgery. Future studies will be required to validate the improvement in skills during surgery.

Engaging medical students in cardiac surgery: a focus on equity, diversity, and inclusion

PURPOSE OF REVIEW

The Coronavirus Disease 2019 pandemic prohibited Canadian medical students from in-person observerships. This may be particularly detrimental to under-represented groups that may consider surgical subspecialties. To address the unprecedented need for alternative surgical career exploration and diversity within the profession, The University of Toronto Cardiac Surgery Interest Group and Division of Cardiac Surgery collaborated on virtual experiential programming.

RECENT FINDINGS

Medical students were invited to virtual (1) observerships of a cardiac bypass case, (2) mentorship sessions with surgeons, (3) resident teaching sessions, (4) multidisciplinary case-based Heart Team discussions to further their understanding of the scope of Cardiac surgery, and (5) a virtual coronary anastomosis training program. Additionally, a comprehensive virtual program was spearheaded to increase interest in Cardiac surgery among low-income Black high school students.

SUMMARY

Trainee response to the virtual education, mentorship, and skill acquisition was positive. Trainees reported high levels of interest in the profession, particularly among females and under-represented minorities, supporting the principles of equity diversity, and inclusion in Cardiac surgery.

Congenital Heart Surgery Training Experiences and Perceptions Among Cardiothoracic Surgery Residents

Interest and core training in congenital heart surgery (CHS) has not been characterized among current cardiothoracic surgical trainees. This study aimed to evaluate perceptions, interest, exposure, and experience among current trainees. A 22 question survey was distributed to all cardiothoracic surgical trainees in ACGME-accredited thoracic surgery residencies. Questions included demographics, exposure to CHS during, perceptions of, participation in and quality assessment of CHS training. There were 106 responses (20.1% response rate) of which 31 (29.0%) were female and 87 (81.3%) were cardiothoracic track. While 69 (64.5%) reported having an interest in CHS at some point during training, only 24 (22.4%) were actively pursuing CHS. All but 7 (6.5%) residents reported having easy access to congenital mentorship, with 35 (32.7%) actively participating in CHS research. Three months was the median duration of congenital rotations. Residents reported less operative participation on CHS compared to adult cardiac surgery. Several residents noted the need for earlier exposure and increased technical/operative experience as areas in need of improvement. The most cited primary influences to pursue CHS included: mentorship, breadth of pathology, and technical nature of the specialty. Lack of consistent job availability and length of additional training were reported as negative influences. Cardiothoracic residents report adequate exposure to obtain case requirements and knowledge for board examinations in CHS but highly variable operative involvement. Mentorship and early exposure remain important for those interested in CHS, while additional training time and limited job availability remain hurdles to CHS.

Application of 3D printing technology combined with PBL teaching model in teaching clinical nursing in congenital heart surgery: A case-control study

We aimed to explore the application of three-dimensional (3D) printing technology with problem-based learning (PBL) teaching model in clinical nursing education of congenital heart surgery, and to further improve the teaching quality of clinical nursing in congenital heart surgery. In this study, a total of 132 trainees of clinical nursing in congenital heart surgery from a grade-A tertiary hospital in 2019 were selected and randomly divided into 3D printing group or traditional group. The 3D printing group was taught with 3D printed heart models combined with PBL teaching technique, while the traditional group used conventional teaching aids combined with PBL technique for teaching. After the teaching process, the 2 groups of nursing students were assessed and surveyed separately to evaluate the results. Compared to the traditional group, the theoretical scores, clinical nursing thinking ability, self-evaluation for comprehensive ability, and teaching satisfaction from the questionnaires filled by the 3D printing group were all higher than the traditional group. The difference was found to be statistically significant (P < .05). Our study has shown the 3D printing technology combined with the PBL teaching technique in the clinical nursing teaching of congenital heart surgery achieved good results.

Implementation of a protocol to increase the academic productivity of cardiothoracic surgery resident physicians

OBJECTIVE

Academic productivity during cardiothoracic surgery residency training is an important program metric, but is highly variable due to multiple factors. This study evaluated the influence of implementing a protocol to increase resident physicians' academic productivity in cardiac surgery.

METHODS

A comprehensive protocol for cardiac surgery was implemented at our institution that included active pairing of residents with academically productive faculty, regular research meetings, centralized data storage and analysis with a core team of biostatisticians, a formal peer-review protocol for analytic requests, and project prioritization and feedback. We compared cardiothoracic surgery residents' academic productivity before implementation (July 2015-June 2017) versus after implementation (July 2017-June 2019). Academic productivity was measured by peer-reviewed articles, abstract presentations (oral or poster) at national cardiothoracic surgery meetings, and textbook chapters.

RESULTS

Thirty-four resident physicians (from traditional and integrated programs) trained at our institution during the study. A total of 122 peer-reviewed articles were produced over the course of the study: 74 (60.7%) cardiac- and 48 (39.3%) thoracic-focused. The number of cardiac-focused resident-produced articles increased from 10 preimplementation to 64 postimplementation (0.61 vs 2.03 articles per resident; P < .01). Abstract oral or poster presentations also increased, from 11 to 40 (0.61 vs 1.33 abstracts per resident; P = .01). Textbook chapters increased from 4 to 15 following the intervention (0.22 vs 0.5 chapters per resident; P = .01).

CONCLUSIONS

Implementation of a dedicated protocol to facilitate faculty mentoring of resident research and streamline the data access, analysis, and publication process substantially improved cardiothoracic surgery residents' academic productivity.

Cost-effectiveness of point-of-care viscoelastic haemostatic assays in the management of bleeding during cardiac surgery: protocol for a prospective multicentre pragmatic study with stepped-wedge cluster randomised controlled design and 1-year follow-up (the IMOTEC study)

INTRODUCTION

During cardiac surgery-associated bleeding, the early detection of coagulopathy is crucial. However, owing to time constraints or lack of suitable laboratory tests, transfusion of haemostatic products is often inappropriately triggered, either too late (exposing to prolonged bleeding and thus to avoidable administration of blood products) or blindly to the coagulation status (exposing to unnecessary haemostatic products administration in patients with no coagulopathy). Undue exposition to transfusion risks and additional healthcare costs may arise. With the perspective of secondary care-related costs, the IMOTEC study (Intérêt MédicO-économique de la Thrombo-Elastographie, dans le management transfusionnel des hémorragies péri-opératoires de chirurgies Cardiaques sous circulation extracorporelle) aims at assessing the cost-effectiveness of a point-of-care viscoelastic haemostatic assay (VHA: RoTem or TEG)-guided management of bleeding. Among several outcome measures, particular emphasis will be put on quality of life with a 1-year follow-up.

METHODS AND ANALYSIS

This is a multicentre, prospective, pragmatic study with stepped-wedge cluster randomised controlled design. Over a 36-month period (24 months of enrolment and 12 months of follow-up), 1000 adult patients undergoing cardiac surgery with cardiopulmonary bypass will be included if a periprocedural significant bleeding occurs. The primary outcome is the cost-effectiveness of a VHA-guided algorithm over a 1-year follow-up, including patients' quality of life. Secondary outcomes are the cost-effectiveness of the VHA-guided algorithm with regard to the rate of surgical reexploration and 1-year mortality, its cost per-patient, its effectiveness with regard to haemorrhagic, infectious, renal, neurological, cardiac, circulatory, thrombotic, embolic complications, transfusion requirements, mechanical ventilation free-days, duration of intensive care unit and in-hospital stay and mortality.

ETHICS AND DISSEMINATION

The study was registered at Clinicaltrials.gov and was approved by the Committee for the Protection of Persons of Nantes University Hospital, The French Advisory Board on Medical Research Data Processing and the French Personal Data Protection Authority. A publication of the results in a peer-reviewed journal is planned.

TRIAL REGISTRATION NUMBER

NCT02972684; Pre-results.

How to assemble a low-fidelity simulator for minimally invasive mitral valve surgery

High-fidelity mitral valve simulators can often be cost-prohibitive and their role in surgical minimally invasive mitral training has yet to be validated. Here, we describe an alternative, a low-cost, low-fidelity minimally invasive mitral valve simulator that can be assembled from components that are readily available in the operating room.

Survival analysis of hierarchical learning curves in assessment of cardiac device and procedural safety

Many Americans rely on cardiac surgical procedures and devices such as pacemakers and thrombolytic catheters to treat or manage their cardiovascular diseases. However, the failure of these cardiac devices and procedures could have grave consequences. One reason cardiac devices tended to fail was due to physician error; there is a learning effect for the physician or operator to come up to speed in skillfully implanting devices and conducting procedures. In order to better understand these learning effects, we had previously modeled the resulting learning curve effects in simulations a hierarchical setting with physicians clustered within institutions using our unique methodology (see the work of Govindarajulu et al 2017). Previously, we had employed these in hierarchical linear modeling and also in generalized estimating equations. In this setting, we have demonstrated how to apply similar methodology but revised in a survival analytic framework or time-to-event analyses. Through simulations and real dataset applications, we found that, out of the three shapes modeled to fit the learning curve, the logarithmic shape tended to have the best fit, similar to previous work (see the work of Govindarajulu et al 2017). However, as seen before, modeling the learning rate can be dataset specific and one shape may be better than another. We learned that modeling the learning rate could also be applied in the survival analysis setting through this new methodology. The goal of this paper is to model cardiac device and procedure learning curve effects in a time-to-event setting so that this knowledge may allow for the improvement of both short and long-term patient survival.

3D-printed aortic stenosis model with fragile and crushable calcifications for off-the-job training and surgical simulation

Surgical simulation devices can be helpful and cost-effective adjuncts to on-the-job training. In this tutorial we present our method for creating an aortic stenosis model with realistically fragile and crushable calcifications, using modern 3D-printing techniques.  The model can be used for training and surgical simulation and is an effective aid to learning for young cardiovascular surgeons.

Surgical Training Improves Performance in Minimally Invasive Left Ventricular Assist Device Implantation Without Cardiopulmonary Bypass

OBJECTIVE

We introduced a live animal model for training of minimally invasive implantation of a continuous-flow left ventricular assist device (CF-LVAD) without cardiopulmonary bypass for operator's performance improvement.

DESIGN

After watching a videotape of LVAD implantation on the beating heart through the cardiac apex, the surgical team performed implantation of LVADs into 5 pigs during 3 training sessions in a time series. The procedure success rate, operating time, and technical and global performances by self-evaluation and senior evaluation were compared among the sessions.

SETTING

Animal Experiment Center in Peking University Third Hospital.

PARTICIPANTS

Surgical team comprising a surgical operator, surgical assistant, anesthetist, and scrub nurse performed 3 training sessions in a time series.

RESULTS

The urgent situations requiring proper management were myocardial laceration, massive blood loss, and ventricular arrhythmia induced by hemodynamic instability. After practice, the success rate increased to 100% in session 3. The operating times of session 2 (189.80 ± 14.34min) and session 3 (149.00 ± 22.85min) were significantly lower than that of session 1 (262.20 ± 28.26min). The technical and global performances by self-evaluation and senior evaluation were significantly better in session 3 than session 1.

CONCLUSION

Simulation training with high-fidelity in vivo model for minimally invasive CF-LVAD implantation improves the surgical team's global performance, success rate, and the ability to manage emergency situations in surgery.

Cardiothoracic surgery training grants provide protected research time vital to the development of academic surgeons

BACKGROUND

The Ruth L. Kirschstein Institutional National Research Service Award (T32) provides institutions with financial support to prepare trainees for careers in academic medicine. In 1990, the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute (NHLBI) was replaced by T32 training grants, which became crucial sources of funding for cardiothoracic (CT) surgical research. We hypothesized that T32 grants would be valuable for CT surgery training and yield significant publications and subsequent funding.

METHODS

Data on all trainees (past and present) supported by CT T32 grants at two institutions were obtained (T32), along with information on trainees from two similarly sized programs without CT T32 funding (Non-T32). Data collected were publicly available and included publications, funding, degrees, fellowships, and academic rank. Non-surgery residents and residents who did not pursue CT surgery were excluded.

RESULTS

Out of 76 T32 trainees and 294 Non-T32 trainees, data on 62 current trainees or current CT surgeons (T32: 42 vs Control: 20) were included. Trainees who were supported by a CT T32 grant were more likely to pursue CT surgery after residency (T32: 40% [30/76] vs Non-T32: 7% [20/294], P < .0001), publish manuscripts during residency years (P < .0001), obtain subsequent NIH funding (T32: 33% [7/21] vs Non-T32: 5% [1/20], P = .02), and pursue advanced fellowships (T32: 41% [9/22] vs Non-T32: 10% [2/20], P = .02).

CONCLUSIONS

T32 training grants supporting CT surgery research are vital to develop academic surgeons. These results support continued funding by the NHLBI to effectively develop and train the next generation of academic CT surgeons.

Association of Surgeon Age and Experience With Congenital Heart Surgery Outcomes

BACKGROUND

Surgeon experience concerns both families of children with congenital heart disease and medical providers. Relationships between surgeon seniority and patient outcomes are often assumed, yet there are little data.

METHODS AND RESULTS

This national study used linked data from the American Medical Association Physician Masterfile and the Society of Thoracic Surgeons-Congenital Heart Surgery Database to examine associations between surgeon years since medical school and major morbidity/mortality for children undergoing cardiac surgery. Sensitivity analyses explored the effects of patient characteristics, institutional/surgeon volumes, and various measures of institutional surgeon team experience. In secondary analyses, major morbidity and mortality were examined as separate end points. We identified 206 congenital heart surgeons from 91 centers performing 62 851 index operations (2010-2014). Median time from school was 25 years (range 9-55 years). A major morbidity/mortality occurred in 11.5% of cases. In multivariable analyses, the odds of major morbidity/mortality were similar for early-career (<15 years from medical school, ≈<40 years old), midcareer (15-24 years, ≈40-50 years old), and senior surgeons (25-35 years, ≈50-60 years old). The odds of major morbidity/mortality were ≈25% higher for operations performed by very senior surgeons (35-55 years from school, ≈60-80 years old; n=9044 cases). Results were driven by differences in morbidity. In extensive sensitivity analyses, these effects remained constant.

CONCLUSIONS

In this study of >200 congenital heart surgeons, we found patient outcomes for surgeons with the fewest years of experience to be comparable to those of their midcareer and senior colleagues, within the context of existing referral and support practices. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. Contemporary approaches to training, referral, mentoring, surgical planning, and other support practices might contribute to the observed outcomes of junior congenital heart surgeons being comparable to those of more experienced colleagues. Understanding and disseminating these practices might benefit the medical community at large.

Common Femoral Artery Access on YouTube: What Practices are Being Shown and Who is Delivering the Message?

OBJECTIVES

Novice learners are increasingly turning to YouTube as a learning resource for surgical procedures. One example of such a procedure is common femoral artery puncture and sheath placement. Practitioners in several specialties perform this procedure to access the arterial system for angiography and intervention. We set forth to compare the techniques demonstrated on YouTube by the various specialists, as well as compare each specialty׳s prevalence on this website.

METHODS

YouTube (www.youtube.com) was accessed in December 2015 at multiple time points with a cleared-cache web browser for the keyword search categories: "femoral artery access," "femoral access," and "angiography access." The top 500 videos from each of these keyword searches were analyzed. Videos were categorized by practitioner specialty, technique, duration of video, age of video, and total views. Videos with clear demonstration of femoral artery access were included in the analysis. All industry videos were excluded from the analysis. Categorical variables were compared using Fisher׳s exact test, and continuous variables were compared with the Student׳s t-test.

RESULTS

A total of 2460, 4680 and 1800 videos were found for each keyword search, respectively. Of these, 33 videos clearly demonstrated femoral artery access technique. Vascular specialists, compared to interventional cardiology and radiology, had fewer videos (n = 4 vs. 14) and older videos (3.5 ± 2.1y vs. 2.25 ± 0.5y, p < 0.05). The vascular specialists demonstrated ultrasound-guided access, while interventional cardiology predominantly demonstrated landmark-guided access (p < 0.05).

CONCLUSIONS

Although YouTube and other online resources are being used by novice learners, vascular specialists are underrepresented for femoral artery access, a foundational vascular procedure. Other practitioners demonstrate videos with landmark-guided access and rarely demonstrate ultrasound use. As recognized vascular experts, vascular surgeons should improve their visibility in online learning resources.

Nina Braunwald: A Female Pioneer in Cardiac Surgery

Nina Starr Braunwald, the first female cardiac surgeon, made headlines during a time when almost all specialty surgeons were men. Women have typically been deterred from entering surgical specialties, in part because of their traditional dual burden of managing their households and careers. Instead, female medical students and junior doctors have tended to be more attracted to medical specialties. This was the reality during Dr. Braunwald's venture into medicine in 1949. However, she never allowed negative ideas to keep her from joining a surgical training program. Under the mentorship of the prominent cardiac surgeons Charles Hufnagel and Andrew Morrow, Dr. Braunwald progressed in her career by conducting research that led to her development and implantation of the first prosthetic mitral valve. She was also a great teacher. Dr. Braunwald balanced her personal and professional activities admirably, and her example still inspires female doctors to consider careers in cardiothoracic surgery. In this report, we provide details of her impact on cardiac surgery and insights into her successes.

Blood, Sweat, Toil, and Tears of Surgical Training. Part I: Blood

There may be conflict between the requirements of surgical training and those of the clinical service if training has an impact on clinical outcomes. One area of potential impact is perioperative blood loss. We compared total and 12-hour blood loss after 2,079 consecutive cardiac operations performed over 2 years by trainees and consultants. One- and two-way analyses of variance with EuroSCORE and surgeon status as factors were carried out to evaluate the impact of surgeon status on blood loss. There was no difference in blood loss between consultants and trainees. We also compared the rates between consultants and trainees of patients returning to the operating room due to bleeding. This showed a significant difference, with trainees having a higher rate of investigation for bleeding. Cardiac surgical training can be achieved without an adverse effect on blood loss, but it may be associated with a higher rate of re-intervention for bleeding.

Intermediate-fidelity simulator for self-training in mitral valve surgery

Current training in mitral valve (MV) surgery is affected by many factors, among which are the complexity of surgical procedures and complex three-dimensional anatomy of the MV. An MV repair simulator is proposed in this study as a low-cost, reusable and portable tool to guide trainees at all levels to effectively construct it with the aim of improving their surgical skills in major techniques of MV surgery in an intermediate-fidelity concept. The simulator is a self-made portable box that is supplied with a self-made silicone MV substitute to simulate the flexible property of MV components. The building process is detailed in this study. Surgical procedures were simulated to test the surgical handling.

Emergent Cardiopulmonary Bypass during Cardiac Surgery

During orientation to the cardiac surgery operating room, new staff may not be exposed to emergent situations. Allowing team members the opportunity to practice their roles during less common, high-stakes emergency cardiac surgical scenarios may better prepare them when crises do arise in the OR. The Emergency Cardiopulmonary Bypass Course was developed to meet the needs of new staff starting in cardiac surgery. Recently, the course has expanded to include experienced staff. This communication describes a high fidelity simulation based course that includes four emergent cardiac surgery scenarios.

Low-Fidelity Simulation of Mitral Valve Surgery: Simple and Effective Trainer

OBJECTIVES

Training in mitral valve (MV) surgery is difficult because of its complex 3-dimentional anatomy and sophisticated surgical techniques. The goal of this study was to create an effective and simple simulator to enable the trainee in performing MV repair and replacement techniques in a low-fidelity environment.

METHODS

The MV surgery simulator is a self-shaped sponge integrated into a portable box that can be used for an unrestricted number of procedures. The building process is detailed in this study. MV procedures were performed in which the surgical handling was tested. The total cost was calculated in euros.

RESULTS

The building of the MV simulator resulted in the development of a new low-cost tool for training in MV surgery. The usage of the sponge led to building the MV components with flexible properties and allowing the surgical procedures to be performed in unrestricted numbers. This involved MV replacement in both intra- and supra-annular fashion and MV repair according to the Carpentier classification.

CONCLUSION

Surgical skills in mitral surgery could be improved by usage of the low-fidelity simulator. The high cost of the training for residents and junior surgeons could be effectively reduced by using this low-cost, portable, reusable simulator and its accessories (ring and band).

First nationwide survey of US integrated 6-year cardiothoracic surgical residency program directors

OBJECTIVE

The recently implemented integrated 6-year (I-6) format represents a significant change in cardiothoracic surgical residency training. We report the results of the first nationwide survey assessing I-6 program directors' impressions of this new format.

METHODS

A 28-question web-based survey was distributed to program directors of all 24 Accreditation Council for Graduate Medical Education-accredited I-6 training programs in November 2013. The response rate was a robust 67%.

RESULTS

Compared with graduates of traditional residencies, most I-6 program directors with enrolled residents believed that their graduates will be better trained (67%), be better prepared for new technological advances (67%), and have superior comprehension of cardiothoracic disease processes (83%). Just as with traditional program graduates, most respondents believed their I-6 graduates would be able to independently perform routine adult cardiac and general thoracic operations (75%) and were equivocal on whether additional specialty training (eg, minimally invasive, heart failure, aortic) was necessary. Most respondents did not believe that less general surgical training disadvantaged I-6 residents in terms of their career (83%); 67% of respondents would have chosen the I-6 format for themselves if given the choice. The greater challenges in training less mature and experienced trainees and vulnerability to attrition were noted as disadvantages of the I-6 format. Most respondents believed that I-6 programs represent a natural evolution toward improved residency training rather than a response to declining interest among medical school graduates.

CONCLUSIONS

High satisfaction rates with the I-6 format were prevalent among I-6 program directors. However, concerns with respect to training relatively less experienced, mature trainees were evident.

Simulation in cardiothoracic surgical training: where do we stand?

OBJECTIVES

Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date.

METHODS

We completed a comprehensive search of all publications pertaining to simulation of cardiothoracic surgical procedures by using PubMed.

RESULTS

Numerous cardiothoracic surgical simulators at various stages of development, assessment, and commercial manufacturing have been published to date. There is currently a predominance of models simulating coronary artery bypass grafting and bronchoscopy and a relative paucity of simulators of open pulmonary and esophageal procedures. Despite the wide range of simulators available, few models have been formally assessed for validity and educational value.

CONCLUSIONS

Surgical simulation is becoming an increasingly important educational tool in training cardiothoracic surgeons. Our next steps forward will be to develop an objective, standardized way to assess surgical simulation training compared with the current apprenticeship model.

Epilogue: ethical goals for the future

Based on the experiences of the Hearts and Minds of Ghana authors, I present possible approaches to the ethical questions that clinicians who participate in health missions and disaster relief programs often face.

Pediatric heart surgery in Ghana: three ethical questions

When a group of doctors and nurses from Boston, Massachusetts, provided evaluation and heart surgery to children in Ghana, they encountered three rationing dilemmas: (1) What portion of surgery slots should they reserve for the simplest, most cost-effective surgeries? (2) How much time should be reserved for especially simple, nonsurgical interventions? (3) How much time should be reserved to training local staff to perform such surgeries? This article investigates these three dilemmas.

What are the barriers to training residents in aortic root surgery?

BACKGROUND AND AIM OF THE STUDY

Aortic root surgery is a technically demanding procedure that is performed infrequently by most surgeons, with national mortality rates over 10%. The study aim was to identify the barriers to training residents in this operation.

METHODS

By using univariate and multivariate logistic regression analysis, all consecutive adults (n = 356) undergoing aortic root reconstruction at The Mount Sinai Medical Center between 2007 and 2011 were retrospectively compared according to whether a resident or faculty surgeon performed the procedure. Surveys were then conducted to determine reasons why residents did not perform cases, and to evaluate outcomes of aortic root surgery performed by recent graduates of the program.

RESULTS

Surgical techniques among patients included: root replacement (81%, n = 290) using homograft, composite bioprosthetic or mechanical valved conduits; Ross procedures (17%, n = 53); and other root surgery such as valve-sparing procedures (2%, n = 7). Residents performed 32% (n = 66/204) of cases when they were scrubbed. The incidence of mortality was lower for cases performed by residents (2%, n = 2) compared to faculty (4%, n = 12) (p=0.335), and no significant differences in cardiopulmonary bypass or cross-clamp times, early morbidity or late survival were observed. The most common reasons given why scrubbed residents did not perform cases were a mismatch between the skill of the resident and case complexity (46%, n = 94), followed by the faculty surgeon's preference (41%, n = 83). Recent program graduates had collectively performed 30 aortic root procedures independently as faculty surgeons, and with no mortality; however, most expressed a continued preference for more senior help on such cases.

CONCLUSION

Residents can safely perform aortic root surgery under appropriate supervision. The greatest challenge involved in improving resident training in aortic root surgery lies in routinely matching resident skills with case complexity and teaching expertise.

Introduction of cardiac surgery residency program at an earlier stage in surgical training

OBJECTIVE

Reform of the Japanese postgraduate residency program has dramatically influenced the recruitment system. Because shortage of young cardiac surgeons is anticipated, an effective program for residents who want to become cardiac surgeons must be established at an earlier stage in surgical training.

METHODS

A 3-year cardiac surgery residency curriculum was developed for senior residents. The surgical training program includes harvesting of the saphenous vein, radial artery and internal thoracic artery, and repair of abdominal aortic aneurysm and specifies the target number of surgical procedures for each training. Academic training is provided in addition to clinical skills training. Nine residents completed the 3-year program between 2004 and 2012. The number of surgical procedures performed, presentations made at scientific meetings, and scientific papers published were investigated and analyzed.

RESULTS

Each resident participated in 438 operations during 3-year program, 25.9 ± 8.3 (5.9 %) as main operator and 182.2 ± 15.8 (42 %) as first assistant. The average number of procedures per resident over the 3 years was 43.0 ± 6.7 for saphenous vein harvest, 14.4 ± 3.9 for radial artery harvest, 27.9 ± 13.0 for internal thoracic artery harvest, 7.1 ± 4.6 for abdominal aortic aneurysm. In addition, over the 3 years, the mean number of presentations at scientific meetings was 13.2 ± 3.2 and the mean number of publication of scientific papers was 1.9 ± 1.4.

CONCLUSION

The new cardiac surgery training curriculum for residents worked fairly well. A system for assessment of the program by an authoritative body should be established in the future.

Emerging alternative model for cardiothoracic surgery training in India

BACKGROUND

In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general surgery residency with certification (MS/DNB) is required for entering 3 years of thoracic surgery residency (MCh/DNB). There are two certifying boards at the national level. One being the Medical Council of India (MCI), which oversees the major accreditation process involving the undergraduate and postgraduate medical education in India, and the other being the National Board of Examinations (NBE), which was formed for the purpose of establishing a uniform standard of postgraduate medical education. Recently, the latter body has come up with an alternative model for thoracic surgery residency in India. This model includes an integrated 6-year residency, with lesser emphasis on general surgical skills and greater exposure to CT surgery.

CONCLUSIONS

Changes to the current model of training for CT surgery is the need of the hour and should be initiated very soon by the MCI to meet the future demand for CT surgeons in India. An integrated training program is essential to create a new generation of cardiovascular specialists. Future directions to achieve this goal must include modifications to the undergraduate programs so as to infuse interest for CT surgery in the young minds of medical students.

A catheterization-training simulator based on a fast multigrid solver

A VR-based simulator helps trainees develop skills for catheterization, a fundamental but difficult procedure in vascular interventional radiology. A deformable model simulates the complicated behavior of guide wires and catheters, using the principle of minimum total potential energy. A fast, stable multigrid solver ensures realistic simulation and real-time interaction. In addition, the system employs geometrically and topologically accurate vascular models based on improved parallel-transport frames, and it implements efficient collision detection. Experiments evaluated the method's stability, the solver's execution time, how well the simulation preserved the catheter's curved tip, and the catheter deformation's realism. An empirical study based on a typical selective-catheterization procedure assessed the system's feasibility and effectiveness.

Reflections on a heart surgery career with insights for Western-trained medical specialists in developing countries

Herein, I describe my experience (spanning 40 years) in helping to develop the specialty of cardiovascular surgery in Syria. Especially in the early years, the challenges were daunting. We initially performed thoracic, vascular, and closed-heart operations while dealing with inadequate facilities, bureaucratic delays, and poorly qualified personnel. After our independent surgical center was established in early 1976, we performed 1 open-heart and 1 closed-heart procedure per day. Open-heart procedures evolved from the few and simple to the multiple and complex, and we solved difficulties as they arose. Today, our cardiac surgical center occupies an entire 6-floor building. We have 12 cardiac surgeons, 10 surgical residents, a formal 6-year surgical residency program, a pediatric cardiac unit, an annual caseload of 1,600, and plans to double our productivity in 2 years. The tribulations of establishing sophisticated surgical programs in a developing country are offset by the variety of clinicopathologic conditions that are encountered, and even more so by the psychological rewards of overcoming adversity and serving a population in need. This account may prove to be insightful for Western-trained physicians who seek to develop specialized medical care in emerging societies.

Can private, non-university-affiliated cardiothoracic training programs provide sufficient surgical experience in cardiac tumors?

Surgical case volumes in non-university-affiliated cardiothoracic surgery training programs in the US have been extensively studied by the Residency Review Committee (RRC) for thoracic surgery. The RRC has established that these programs offer a broad experience in common cardiothoracic procedures such as myocardial revascularization, valvular surgery, and cardiopulmonary transplantation. However, resident exposure to other important but less common cardiac surgical conditions in these programs remains unanswered. To address this question, an institutional review board-approved retrospective review of the experience of thoracic surgery residents with one of the rarest of surgical conditions, cardiac tumors, was conducted at the Ochsner Clinic Foundation in New Orleans, Louisiana. A survey of existing private, non-university-affiliated US cardiothoracic surgery training programs was conducted to determine the extent of the cardiac tumor experience in these programs. The results were then compared with selected university programs.