Recent Applications of Three Dimensional Printing in Cardiovascular Medicine

Three dimensional (3D) printing, which consists in the conversion of digital images into a 3D physical model, is a promising and versatile field that, over the last decade, has experienced a rapid development in medicine. Cardiovascular medicine, in particular, is one of the fastest growing area for medical 3D printing. In this review, we firstly describe the major steps and the most common technologies used in the 3D printing process, then we present current applications of 3D printing with relevance to the cardiovascular field. The technology is more frequently used for the creation of anatomical 3D models useful for teaching, training, and procedural planning of complex surgical cases, as well as for facilitating communication with patients and their families. However, the most attractive and novel application of 3D printing in the last years is bioprinting, which holds the great potential to solve the ever-increasing crisis of organ shortage. In this review, we then present some of the 3D bioprinting strategies used for fabricating fully functional cardiovascular tissues, including myocardium, heart tissue patches, and heart valves. The implications of 3D bioprinting in drug discovery, development, and delivery systems are also briefly discussed, in terms of in vitro cardiovascular drug toxicity. Finally, we describe some applications of 3D printing in the development and testing of cardiovascular medical devices, and the current regulatory frameworks that apply to manufacturing and commercialization of 3D printed products.

Simulation training for continuing professional development of nurses in cardiology and cardiovascular surgery

BACKGROUND

  Nurses play a key role in cardiac arrest management, especially those assigned to cardiac intensive care units, where they are often actively involved in cardiopulmonary resuscitation.

AIM

To evaluate the effect of simulation training in in continuing professional development of nurses in this setting.

METHODS

A comparative study using paired samples (where the candidate was his own control with repeated measures before and after intervention), was conducted among nurses working in the cardiology and cardiovascular surgery division of our institution. The primary endpoint was the change in skills judged on the basis of competency score of 20 assessed before and after simulation training.

RESULTS

32 nurses participated in the training session. Despite a median job seniority of 8.5 years [4.0 - 12.5], only 44% of nurses had already participated in a simulation session. Although most of the candidates (84%) had previously performed chest compressions, only 34% had delivered an electrical defibrillation during their exercise. We showed a significant increase in overall scores from 8.0 [5.0 - 9.8] to 17.5 [17.0 - 19.0] after the simulation training session (p<0.0001). All the criteria judged in the evaluation grid (basic life support, manual electrical defibrillation) were significantly improved and the most positive effect was observed in the manual defibrillation where the prior experience of the participants was limited.

CONCLUSIONS

Simulation learning had a major positive impact on the development of nurses' skills in terms of cardiopulmonary resuscitation.

VCSim3: a VR simulator for cardiovascular interventions

PURPOSE

Effective and safe performance of cardiovascular interventions requires excellent catheter/guidewire manipulation skills. These skills are currently mainly gained through an apprenticeship on real patients, which may not be safe or cost-effective. Computer simulation offers an alternative for core skills training. However, replicating the physical behaviour of real instruments navigated through blood vessels is a challenging task.

METHODS

We have developed VCSim3-a virtual reality simulator for cardiovascular interventions. The simulator leverages an inextensible Cosserat rod to model virtual catheters and guidewires. Their mechanical properties were optimized with respect to their real counterparts scanned in a silicone phantom using X-ray CT imaging. The instruments are manipulated via a VSP haptic device. Supporting solutions such as fluoroscopic visualization, contrast flow propagation, cardiac motion, balloon inflation, and stent deployment, enable performing a complete angioplasty procedure.

RESULTS

We present detailed results of simulation accuracy of the virtual instruments, along with their computational performance. In addition, the results of a preliminary face and content validation study conveyed on a group of 17 interventional radiologists are given.

CONCLUSIONS

VR simulation of cardiovascular procedure can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. VCSim3 is still a prototype, yet the initial results indicate that it provides promising foundations for further development.

[The Past, Present and Future of the Japanese Board of Cardiovascular Surgery]

The Japanese Board of Cardiovascular Surgery(JBCVS) was established in 2002 by 3 surgical societies. The JBCVS was designed to function as a committee independent from these 3 surgical societies. Even though we revised and updated the several requirements for residents and renewal in board holders, the number of specialists increased and reaches 1,900 recently. In May 2014, Japan's Ministry of Health, Labor and Welfare announced plans to renew the Japanese Medical Specialty Board system. The new system aims to qualify doctors not by their own academic societies but by an independent committee [the Japanese Medical Specialty Board (JMSB) established in April 2014] and to monitor and ensure continuous lifetime education in order to provide high-quality and appropriate medical care to the people of Japan and to increase the public's trust in their medical providers. Under the JMSB, a new training system for cardiovascular surgeons will start in few years. The JBCVS is now preparing standard guidelines for its training programs and will submit them to the JMSB for evaluation. We would like to build up an efficient and better training environment while eliminating the problems in the present system prior to the establishment of a new board qualification system. Therefore, we decided to start several changes and new trials in present requirements for specialists from 2017.

[Japan Cardiovascular Surgery Database: past and future]

The Japan Cardiovascular Surgery Database (JCVSD) was established in 2000 to contribute to quality improvement in cardiovascular surgery nationwide. Data are entered via the Internet, and variables were imported from the Society of Thoracic Surgeons National Database of North America. At present, the number of participating hospitals exceeds 500, and the cumulative number of data entries exceeds 220,000. In 2008, a risk model was created from this large database, and a risk calculator, JapanSCORE, was launched. JapanSCORE assists not only cardiac surgeons but also cardiologists and other physicians to determine the expected mortality risk of a specific patient instantly via the Internet. The JCVSD has three ad hoc committees: the Variable Specification Committee; Site Visit Committee; and Data Access Committee. The Variable Specification Committee responds to questions from participating surgeons regarding database variables and definitions, and an FAQ section was developed based on those queries. The Site Visit Committee visits a number of hospitals monthly for auditing. The Data Access Committee handles applications submitted for data analysis usage from participating hospitals. Based on those data analyses, more than 20 frequently cited papers have been published in international medical journals. Recently, the JCVSD has been linked with the board certification system in the field of cardiovascular medicine, in which almost all hospitals in Japan participate, and it was used for board certification in 2013 for the first time.

[Clinical simulation as a training tool for clinical teams and care change facilitator]

OBJECTIVE

The objective of this article is to describe and show the results of a simulation training interprofesional program to meet a training need of Surgical area professionals in management in cardiovascular surgery emergencies in Valdecilla Hospital.

MATERIAL

The activity was aimed to train at the 42 nurses in rotation in the surgical area, nursing assistances, cardiovascular surgeons and anesthetists. For it was made a study of the training needs and were designed clinical simulation escenarios, theoretical sessions as well in workshops usual workplace.

RESULTS

The training project was conducted in four phases between May 21 to June 18, 2012, within which were 3 clinical cases for multidisciplinary training in emergency usual CCV. With the full participation of 65 professionals and 17 instructors, after further analysis to cases, results were achieved improved teamwork, and picked up, several changes to be made in the organization of the service.

CONCLUSIONS

Clinical simulation mode responds to adult learning, based on their own experience and personal reflection, and all in an environment that does not risk to patients or professionals. It is really helpful and flexible to meet different institutional challenges and where participants highlighted two key aspects in this activity such as the multidisciplinary team where they could train the professional standard and the possibility of analysis and reflection after the event to share experiences and look for areas of improvement among all the clinical team.

Evaluation of skill-acquisition process in mitral valve repair techniques: a simulation-based study

INTRODUCTION

Increased patient awareness, duty-hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgical education. A bovine heart model was designed for training in mitral valve repair procedures. In this article, we aimed to share our experience with this model and to test the validity of simulation with respect to skill acquisition during the training course.

METHODS

After reviewing instructional video recordings of mitral valve repair techniques, 5 junior residents (first and second year) and 5 senior residents (year 4 or higher), who had no experience in mitral valve repair surgery previously, performed mitral valve repair techniques on bovine heart model in a three-month period. Nine different internet videos demonstrating surgical techniques were watched prior to performance in each case. Different text books were studied before the study course. Following repair in each case, the left ventricle of each bovine heart was statically pressurized, the coaptation depth was measured, and the regurgitation (if any) was scored. Each performance was recorded. At the end of the study, video records were evaluated in a blind fashion by 3 different surgeons experienced in mitral valve repair techniques. The monthly scores obtained were statistically analyzed.

RESULTS

The mean coaptation depth values measured on a monthly basis were as follows: 2.75±0.63, 4.90±0.91, and 6.55±0.88 for the junior residents and 4.30±0.65, 5.45±0.68, and 7.00±0.64mm for the senior residents. Regurgitation scores noted were 2.20±0.52, 1.65±0.58, and 0.10±0.30 for the junior residents and 1.50±0.60, 0.65±0.67, and 0.70±0.65 for the senior residents During the study period, the practice improved in terms of the aforementioned parameters in both groups (p<0.05).

CONCLUSIONS

This simulation model of mitral valve repair helped in skill acquisition on monthly basis in both resident groups.

[Trends in live demonstrations of cardiovascular surgery in Japan and the ideal form of live demonstration]

Live demonstrations of cardiovascular surgery are performed following guidelines instituted in 2007. The guidelines suggest that standard procedures should be selected and performed at institutions qualified by the Japanese Board of Cardiovascular Surgery. Live demonstrations should be approved by each institutional review board, and the setting of live demonstrations should allow the surgeons to concentrate on the procedures. Live demonstrations are one tool for educating a large audience simultaneously, but the surgeons may not always be able to perform at their best. The ideal live demonstrations should have the greatest educational impact with minimum risk to patients. The guidelines may play an important role in achieving this goal. However, live demonstrations may not be considered cost-effective if only routine procedures are performed. We should seek permanent, less expensive, and more effective forms of live demonstrations while ensuring patient safety.

[Guidelines on live demonstrations of thoracic and cardiovascular surgery: pros and cons]

Guidelines on live demonstrations of cardiothoracic surgery were established in Japan following a single incident of an inappropriately performed live demonstration of an open repair of a thoracic aneurysm. Although the guidelines have contributed to ensuring patient safety and privacy, live demonstrations of surgical procedures in Japan have nearly been eliminated due to their strict regulations. However, since the guidelines only apply to surgeons who belong to surgical societies, live demonstrations performed by interventionalists are still performed without following the guidelines. Furthermore, the guidelines regulate both open repair as well as interventional procedures. Some procedures, such as stent graft and laparoscopic procedures, are suited for live demonstrations and some are not, and the guidelines should be tailored to each procedure. At Jikei University, we have held seven live demonstration symposiums with 5,700 participants, of whom 90% provided positive feedback on the value of the live demonstrations. In addition, a survey showed that the morbidity and mortality rates of the 122 live demonstrations performed during this period did not differ from those of similar procedures performed conventionally at our institution, indicating that live demonstration surgery can be performed without compromising safety. If performed by experienced surgeons obeying the guideline, live demonstration surgery is an effective, safe educational tool.

[Interest of evaluation of teaching in thoracic and cardiovascular surgery]

The aim of this work is to reflect on different teaching methods can be used in a surgical teaching and its assessment methods. TWO sessions of Multiple Choice Questions (MCQ) have been proposed, the first before all education, the second after education in order to assess its impact on knowledge. Script Concordance Test (SCT) will replace the traditional interactive case report. Eighteen participants (Group 1) completed both sessions of MCQ: 9 residents (R), 2 equivalent resident (ER), 4 Clinical Fellow (CF), 1 Professor (Pr) and 2 senior surgeons (SS). Sixteen participants (group 2) were present at the first session of MCQ: 6 R, 1 ER, 4 CF, 2 Pr, 2 SS and 1 indeterminate status. Finally, 12 participants (group 3) were present at the second session: 6 R, 1 ER, 1 CF, 1 SS and 3 indeterminate status. The results of"seniors" in Group 1 were higher than those of "juniors" at the first session. MCQ results for the second session were higher in the subgroup CF. A more marked progression in knowledge was observed in resident and Clinical Fellow. Finally, the score obtained by the group 3 was lower than in group 1. The format of the MCQ was particularly heterogeneous. The SCT will help to assess the capacity of decision making in a context of uncertainty (as unexpected surgery requiring quick decisions with immediate effect, surgical strategy in an unusual clinical situation). The different tools available would allow the establishment of an evaluation of teaching, but also to assess the development of thinking skills in situations of uncertainty. Their implementation will take place with the participation and support of the largest number of teachers in our specialty.

[Recent 10-year progress of board certificated cardiovascular surgeon]

The recent 10-year progress and prospective views of the Board Certificated Cardiovascular Surgeon in Japan were described. Although total framework of the Japanese Board of Medical Specialist is not yet established, the certification standards of the Board Certificated Cardiovascular Surgeon and training hospital were substantially revised in 2005 and 2006 for increasing those quality. Hereafter, we should tackle to make new systems for the trainee's registration, gaining of incentive for the Board Certificated Cardiovascular Surgeon, and education of coworkers in surgical fields.

Impact of the European Working Time Directive on exposure to operative cardiac surgical training☆

OBJECTIVE

To evaluate the impact of the reduced working hours, an anticipated decline in case load and increasing patient risk profile, we performed a cohort study to determine the factors that influenced operative surgical training.

METHODS

A historic cohort study design was utilised, and data were acquired from a prospective operative surgical database a year before, and a year after the introduction of the European Working Time Directive (EWTD) compliant rota (1st August 2004). Logistic regression was used to determine the predictors of operative surgical training, and individual variables were ranked by likelihood ratio.

RESULTS

In total, 3312 cardiac surgical operations were performed over a 2-year period between 3rd August 2003 and 31st July 2005. The proportion of cases performed by trainees was 39% (626/1587) in the year before and 40% (695/1725) in the year after the introduction of WTD compliant rota. There were no differences in operative risk (logistic EuroSCORE of 8, P=0.853). Independent predictors for surgery performed by a trainee (in descending order of influence) were the consultant in charge (chi11(2) 273.1; P<0.001), procedure performed (chi5(2) 163.5; P<0.001), increasing seniority of trainee (chi2(2) 142.3; P<0.001), revision surgery (chi1(2) 45.9; P<0.001), lower EuroSCORE (chi1(2) 17.6; P<0.001), and better ventricular function (chi2(2) 7.8; P=0.020). The odds ratio of an operation performed by a trainee increased after the introduction of the EWTD compliant rota to 1.19 (95% CI 1.00-1.41; P=0.045).

CONCLUSIONS

With a successful institution-specific training module and a commitment to training, exposure to operative surgical training can be sustained despite shortening of working hours.