The Incorporation of Hands-On Surgical Training in a Congenital Heart Surgery Training Curriculum

Assessment of a Novel, Adjustable Task Trainer for Cardiac Surgical Skills

INTRODUCTION

A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment.

METHODS

Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity.

RESULTS

The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043).

CONCLUSIONS

Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room.

Longitudinal Evaluation of Congenital Cardiovascular Surgical Performance and Skills Retention Using Silicone-Molded Heart Models

Objective: Hands-on surgical training (HOST) for congenital heart surgery (CHS), utilizing silicone-molded models created from 3D-printing of patients' imaging data, was shown to improve surgical skills. However, the impact of repetition and frequency of repetition in retaining skills has not been previously investigated. We aimed to longitudinally evaluate the outcome for HOST on two example procedures of different technical difficulties with repeated attempts over a 15-week period. Methods: Five CHS trainees were prospectively recruited. Repair of coarctation of the aorta (CoA) and arterial switch operation (ASO) were selected as example procedures of relatively low and high technical difficulty. Procedural time and technical performance (using procedure-specific assessment tools by the participant, a peer-reviewer, and the proctor) were measured. Results: Coarctation repair performance scores improved after the first repetition but remained unchanged at the follow-up session. Likewise, CoA procedural time showed an early reduction but then remained stable (mean [standard deviation]: 29[14] vs 25[15] vs 23[9] min at 0, 1, and 4 weeks). Conversely, ASO performance scores improved during the first repetitions, but decreased after a longer time delay (>9 weeks). Arterial switch operation procedural time showed modest improvements across simulations but significantly reduced from the first to the last attempt: 119[20] versus 106[28] min at 0 and 15 weeks, P = .049. Conclusions: Complex procedures require multiple HOST repetitions, without excessive time delay to maintain long-term skills improvement. Conversely, a single session may be planned for simple procedures to achieve satisfactory medium-term results. Importantly, a consistent reduction in procedural times was recorded, supporting increased surgical efficiency.

Simulating mitral repair: lessons learned

PURPOSE OF REVIEW

With the growing complexity of cardiac surgical cases, increased focus on patient safety, and minimally invasive techniques, simulation-based training has experienced a renaissance. This review highlights important elements of simulation-based training, focusing specifically on available simulators for mitral valve repair and the uses for simulation.

RECENT FINDINGS

Referring to simulators as being high or low fidelity is oversimplified. Fidelity is a multifactorial concept, and for surgical task trainers, structural and functional fidelity should be discussed. For mitral valve repair, there are a spectrum of simulators, including tissue-based models, bench-top models, and hybrid models. All these simulator modalities serve a role in training if they align with predetermined objectives. There have been advancements in mitral valve repair simulation, notably patient-specific 3D printed silicone replicas of disease.

SUMMARY

There is evidence to support that simulation improves performance in the simulated environment, but future investigation should look to determine whether simulation improves performance in the clinical setting and ultimately patient outcomes.

The introduction of surgical simulation on three-dimensional-printed models in the cardiac surgery curriculum: an experimental project

AIMS

Training in congenital cardiac surgery has become more and more difficult because of the reduced opportunities for trainees in the operating room and the high patient anatomical variability. The aim of this study was to perform a pilot evaluation of surgical simulation on a simple 3D-printed heart model in training of young surgeons and its potential inclusion in the curriculum of residency programs.

METHODS

A group of 11 residents performed a surgical correction of aortic coarctation using a 3D-printed surgical model. After teaching the surgical procedure, a simulation was performed twice, at different times, and was evaluated quantitatively and qualitatively by a senior surgeon. A 3D model-based training program was then developed and incorporated into our cardiac surgery training program.

RESULTS

A significant improvement in surgical technique was observed between the first and second surgical simulations: median of 65% [interquartile range (IQR) = 61-70%] vs. 83% (IQR = 82-91%, P < 0.001). The median time required to run the simulation was significantly shorter during the second simulation: 39 min (IQR = 33-40) vs. 45 min (IQR = 37-48; P = 0.02). Regarding the simulation program, a basic and an advanced program were developed, including a total of 40 different simulated procedures divided into 12 sessions.

CONCLUSION

Surgical simulation using 3D-printing technology can be an extremely valuable tool to improve surgical training in congenital heart disease. Our pilot study can represent the first step towards the creation of an integrated training system on 3D-printed models of congenital and acquired heart diseases in other Italian residency programs.

Patient-Specific 3D-Printed Low-Cost Models in Medical Education and Clinical Practice

3D printing has been increasingly used for medical applications with studies reporting its value, ranging from medical education to pre-surgical planning and simulation, assisting doctor-patient communication or communication with clinicians, and the development of optimal computed tomography (CT) imaging protocols. This article presents our experience of utilising a 3D-printing facility to print a range of patient-specific low-cost models for medical applications. These models include personalized models in cardiovascular disease (from congenital heart disease to aortic aneurysm, aortic dissection and coronary artery disease) and tumours (lung cancer, pancreatic cancer and biliary disease) based on CT data. Furthermore, we designed and developed novel 3D-printed models, including a 3D-printed breast model for the simulation of breast cancer magnetic resonance imaging (MRI), and calcified coronary plaques for the simulation of extensive calcifications in the coronary arteries. Most of these 3D-printed models were scanned with CT (except for the breast model which was scanned using MRI) for investigation of their educational and clinical value, with promising results achieved. The models were confirmed to be highly accurate in replicating both anatomy and pathology in different body regions with affordable costs. Our experience of producing low-cost and affordable 3D-printed models highlights the feasibility of utilizing 3D-printing technology in medical education and clinical practice.

Patient-Specific 3D-Printed Models in Pediatric Congenital Heart Disease

Three-dimensional (3D) printing technology has become increasingly used in the medical field, with reports demonstrating its superior advantages in both educational and clinical value when compared with standard image visualizations or current diagnostic approaches. Patient-specific or personalized 3D printed models serve as a valuable tool in cardiovascular disease because of the difficulty associated with comprehending cardiovascular anatomy and pathology on 2D flat screens. Additionally, the added value of using 3D-printed models is especially apparent in congenital heart disease (CHD), due to its wide spectrum of anomalies and its complexity. This review provides an overview of 3D-printed models in pediatric CHD, with a focus on educational value for medical students or graduates, clinical applications such as pre-operative planning and simulation of congenital heart surgical procedures, and communication between physicians and patients/parents of patients and between colleagues in the diagnosis and treatment of CHD. Limitations and perspectives on future research directions for the application of 3D printing technology into pediatric cardiology practice are highlighted.

Simulation in thoracic surgery-A mini review of a vital educational tool to maximize peri-operative care and minimize complications

Thoracic surgery is an increasingly expanding field, and the addition of national screening programs has resulted in increasing operative numbers and complexity. Thoracic surgery overall has an approximately 2% mortality and 20% morbidity with common specific complications including persistent air leak, pneumothorax, and fistulas. The nature of the surgery results in complications being unique to thoracic surgery and often very junior members of the surgical team feel underprepared to deal with these complications after very little exposure during their medical school and general surgical rotations. Throughout medicine, simulation is being increasingly used as a method to teach the management of complicated, rare, or significant risk occurrences and has shown significant benefits in learner confidence and outcomes. In this mini review we explain the learning theory and benefits of simulation learning. We also discuss the current state of simulation in thoracic surgery and its potential future in aiding complication management and patient safety.

Congenital Heart Surgery Skill Training Using Simulation Models: Not an Option but a Necessity

Congenital heart surgery (CHS) is technically demanding, and its training is extremely complex and challenging. Training of the surgeon's technical skills has relied on a preceptorship format in which the trainees are gradually exposed to patients in the operating room under the close tutelage of senior staff surgeons. Training in the operating room is an inefficient process and the concept of a learning curve is no longer acceptable in terms of patient outcomes. The benefits of surgical simulation in training of congenital heart surgeons are well known and appreciated. However, adequate surgical simulation models and equipment for training have been scarce until the recent development of three-dimensionally (3D) printed models. Using comprehensive 3D printing and silicone-molding techniques, realistic simulation training models for most congenital heart surgical procedures have been produced. Newly developed silicone-molded models allow efficient CHS training in a stress-free environment with instantaneous feedback from the proctors and avoids risk to patients. The time has arrived when all congenital heart surgeons should consider surgical simulation training before progressing to real-life operating in a similar fashion to the aviation industry where all pilots are required to complete simulation training before flying a real aircraft. It is argued here that simulation training is not an option anymore but should be a mandatory component of CHS training.

The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: a systematic review

OBJECTIVES

With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.

METHODS

Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.

CONCLUSIONS

Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

Imaging-Based, Patient-Specific Three-Dimensional Printing to Plan, Train, and Guide Cardiovascular Interventions: A Systematic Review and Meta-Analysis

BACKGROUND

To tailor cardiovascular interventions, the use of three-dimensional (3D), patient-specific phantoms (3DPSP) encompasses patient education, training, simulation, procedure planning, and outcome-prediction.

AIM

This systematic review and meta-analysis aims to investigate the current and future perspective of 3D printing for cardiovascular interventions.

METHODS

We systematically screened articles on Medline and EMBASE reporting the prospective use of 3DPSP in cardiovascular interventions by using combined search terms. Studies that compared intervention time depending on 3DPSP utilisation were included into a meta-analysis.

RESULTS

We identified 107 studies that prospectively investigated a total of 814 3DPSP in cardiovascular interventions. Most common settings were congenital heart disease (CHD) (38 articles, 6 comparative studies), left atrial appendage (LAA) occlusion (11 articles, 5 comparative, 1 randomised controlled trial [RCT]), and aortic disease (10 articles). All authors described 3DPSP as helpful in assessing complex anatomic conditions, whereas poor tissue mimicry and the non-consideration of physiological properties were cited as limitations. Compared to controls, meta-analysis of six studies showed a significant reduction of intervention time in LAA occlusion (n=3 studies), and surgery due to CHD (n=3) if 3DPSPs were used (Cohen's d=0.54; 95% confidence interval, 0.13 to 0.95; p=0.001), however heterogeneity across studies should be taken into account.

CONCLUSIONS

3DPSP are helpful to plan, train, and guide interventions in patients with complex cardiovascular anatomy. Benefits for patients include reduced intervention time with the potential for lower radiation exposure and shorter mechanical ventilation times. More evidence and RCTs including clinical endpoints are needed to warrant adoption of 3DPSP into routine clinical practice.

Translating Imaging Into 3D Printed Cardiovascular Phantoms

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3D printed patient specific phantoms can visualize complex cardiovascular anatomy

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Common imaging modalities for 3D printing are CCT and CMR

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Material jetting/PolyJet and stereolithography are widely used printing techniques

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Standardized validation is warranted to compare different 3D printing technologies

Translation of imaging into 3-dimensional (3D) printed patient-specific phantoms (3DPSPs) can help visualize complex cardiovascular anatomy and enable tailoring of therapy. The aim of this paper is to review the entire process of phantom production, including imaging, materials, 3D printing technologies, and the validation of 3DPSPs. A systematic review of published research was conducted using Embase and MEDLINE, including studies that investigated 3DPSPs in cardiovascular medicine. Among 2,534 screened papers, 212 fulfilled inclusion criteria and described 3DPSPs as a valuable adjunct for planning and guiding interventions (n = 108 [51%]), simulation of physiological or pathological conditions (n = 19 [9%]), teaching of health care professionals (n = 23 [11%]), patient education (n = 3 [1.4%]), outcome prediction (n = 6 [2.8%]), or other purposes (n = 53 [25%]). The most common imaging modalities to enable 3D printing were cardiac computed tomography (n = 131 [61.8%]) and cardiac magnetic resonance (n = 26 [12.3%]). The printing process was conducted mostly by material jetting (n = 54 [25.5%]) or stereolithography (n = 43 [20.3%]). The 10 largest studies that evaluated the geometric accuracy of 3DPSPs described a mean bias <±1 mm; however, the validation process was very heterogeneous among the studies. Three-dimensional printed patient-specific phantoms are highly accurate, used for teaching, and applied to guide cardiovascular therapy. Systematic comparison of imaging and printing modalities following a standardized validation process is warranted to allow conclusions on the optimal production process of 3DPSPs in the field of cardiovascular medicine.

State-of-the-Art Silicone Molded Models for Simulation of Arterial Switch Operation: Innovation with Parting-and-Assembly Strategy

Background

Methods

Results

Conclusions

Is it time to incorporate hands-on simulation into the cardiothoracic surgery curriculum?

The COVID pandemic has had huge implications for training in cardiothoracic surgery. The reduction in training opportunities has led to concerns from trainees globally regarding the impact on their learning and their training progression. Surgical simulation is effective in the development of technical skills in cardiothoracic surgery with numerous examples of low and high-fidelity simulators. Despite this the incorporation of such methods into training curricula worldwide is seldom. Core fundamentals are required to successfully implement surgical simulation into training programmes, which includes; commitment from trainers, regular sessions and structured feedback. Few programmes have demonstrated the successful incorporation of surgical simulation and there is a growing acceptance of its place in the speciality. As we recover from this challenging period it may be the right opportunity to evolve how we train our current and future trainees by incorporating hands-on simulation as a fundamental part of the cardiothoracic curriculum.

Design and 3D printing of variant pediatric heart models for training based on a single patient scan

Background

3D printed models of pediatric hearts with congenital heart disease have been proven helpful in simulation training of diagnostic and interventional catheterization. However, anatomically accurate 3D printed models are traditionally based on real scans of clinical patients requiring specific imaging techniques, i.e., CT or MRI. In small children both imaging technologies are rare as minimization of radiation and sedation is key. 3D sonography does not (yet) allow adequate imaging of the entire heart for 3D printing. Therefore, an alternative solution to create variant 3D printed heart models for teaching and hands-on training has been established.

Methods

In this study different methods utilizing image processing and computer aided design software have been established to overcome this shortage and to allow unlimited variations of 3D heart models based on single patient scans. Patient-specific models based on a CT or MRI image stack were digitally modified to alter the original shape and structure of the heart. Thereby, 3D hearts showing various pathologies were created. Training models were adapted to training level and aims of hands-on workshops, particularly for interventional cardiology.

Results

By changing the shape and structure of the original anatomy, various training models were created of which four examples are presented in this paper: 1. Design of perimembranous and muscular ventricular septal defect on a heart model with patent ductus arteriosus, 2. Series of heart models with atrial septal defect showing the long-term hemodynamic effect of the congenital heart defect on the right atrial and ventricular wall, 3. Implementation of simplified heart valves and addition of the myocardium to a right heart model with pulmonary valve stenosis, 4. Integration of a constructed 3D model of the aortic valve into a pulsatile left heart model with coarctation of the aorta. All presented models have been successfully utilized and evaluated in teaching or hands-on training courses.

Conclusions

It has been demonstrated that non-patient-specific anatomical variants can be created by modifying existing patient-specific 3D heart models. This way, a range of pathologies can be modeled based on a single CT or MRI dataset. Benefits of designed 3D models for education and training purposes have been successfully applied in pediatric cardiology but can potentially be transferred to simulation training in other medical fields as well.

3D Modeling and Printing in Congenital Heart Surgery: Entering the Stage of Maturation

3D printing allows the most realistic perception of the surgical anatomy of congenital heart diseases without the requirement of physical devices such as a computer screen or virtual headset. It is useful for surgical decision making and simulation, hands-on surgical training (HOST) and cardiovascular morphology teaching. 3D-printed models allow easy understanding of surgical morphology and preoperative surgical simulation. The most common indications for its clinical use include complex forms of double outlet right ventricle and transposition of the great arteries, anomalous systemic and pulmonary venous connections, and heterotaxy. Its utility in congenital heart surgery is indisputable, although it is hard to "scientifically" prove the impact of its use in surgery because of many confounding factors that contribute to the surgical outcome. 3D-printed models are valuable resources for morphology teaching. Educational models can be produced for almost all different variations of congenital heart diseases, and replicated in any number. HOST using 3D-printed models enables efficient education of surgeons in-training. Implementation of the HOST courses in congenital heart surgical training programs is not an option but an absolute necessity. In conclusion, 3D printing is entering the stage of maturation in its use for congenital heart surgery. It is now time for imagers and surgeons to find how to effectively utilize 3D printing and how to improve the quality of the products for improved patient outcomes and impact of education and training.