Is Porcine Small Intestinal Submucosal Extracellular Matrix (ECM) a Suitable Material for Right Ventricular Outflow Tract Reconstruction in Association With Pulmonary Valve Replacement?

Pulmonary valve replacement (PVR) with right ventricular outflow tract (RVOT) reconstruction is a common congenital cardiac operation. Porcine submucosal intestinal-derived extracellular matrix (ECM) patches have been used for RVOT reconstruction. We present 2 adult patients with Tetralogy of Fallot who underwent PVR with RVOT reconstruction utilizing ECM. Both cases required reoperation due to patch dehiscence causing a large paravalvular leak. One patient also had a pseudoaneurysm associated with ECM dehiscence. There may be a propensity for ECM dehiscence in this application and, based on these cases, we recommend avoidance of ECM in RVOT reconstruction with PVR. PVR patients repaired with ECM should be monitored for this complication.

Improved Outcomes of Heart Transplantation in Adults With Congenital Heart Disease Receiving Regionalized Care.

BACKGROUND: The number of adult congenital heart disease (CHD) patients undergoing heart transplantation is increasing rapidly. CHD patients have higher surgical risk at transplantation. High-volume adult CHD transplant centers may have better transplant outcomes. OBJECTIVES: This study aimed to evaluate the effect of center CHD transplant volume and expertise on transplant outcomes in CHD patients. METHODS: The authors studied heart transplantations in CHD patients age ≥18 years using the United Network of Organ Sharing (UNOS) database for the primary outcomes of waitlist mortality and post-transplant outcomes at 30 days and 1 year. Transplant centers were assessed by status as the highest CHD transplant volume center in a UNOS region versus all others, presence of Adult Congenital Heart Association accreditation, and adult versus pediatric hospital designation. RESULTS: Between January of 2000 and June of 2018, 1,746 adult CHD patients were listed for transplant; 1,006 (57.6%) of these underwent heart transplantation. After adjusting for age, sex, listing status, and inotrope requirement, waitlist mortality risk was lower at Adult Congenital Heart Association accredited centers (hazard ratio: 0.730; p = 0.020). Post-transplant 30-day mortality was lower at the highest volume CHD transplant center in each UNOS region (hazard ratio: 0.706; p = 0.014). CONCLUSIONS: Designated expertise in CHD care is associated with improved waitlist outcomes for CHD patients listed for transplantation. Post-transplant survival was improved at the highest volume regional center. These findings suggest a possible advantage of regionalization of CHD transplantation.

The Surgeon as Educator.

Surgical education in 2019 faces may challenges to maintain the high standards of excellence achieved in prior generations of learners and trainers in cardiothoracic surgery. This compendium hopes to review the current and future strategies in surgical education. The topics include the adult learner, assessing competence, providing formative feedback, developing strategies to minimize implicit bias, optimizing education in the operating room, effective classroom teaching, the future of e-learning, the alternative curriculum, teaching mentorship and coaching, deliberate practice and simulation, faculty development, the potential roles of virtual and augmented reality, and the impact artificial intelligence might have on surgical education in the future.

Flipping the Classroom: How to Optimize Learning in the Didactic Setting.

Classic classroom education emphasizes the teacher imparting knowledge, experience, or wisdom (pedagogy). Adult educational theory indicates learning is optimized in an experiential setting, where the learner prepares, the session is case based, and the responsibility of the educator is to teach what the learner does not know. This is referred to as "flipping the classroom." Flipping the classroom is not simple, as the historical educational culture often changes; and, at least early in the transition process, different expectations, preparation, or training are essential for both the learner and educator for this approach to be effective.

Development of a 3-D printing-based cardiac surgical simulation curriculum to teach septal myectomy.

OBJECTIVE: We sought to develop a 3-D printing-based simulator for teaching extended septal myectomy to trainees in cardiothoracic surgery (clinical postgraduate year 4-7). This procedure is difficult to teach because of generally unfamiliar and highly variable anatomy, limited visibility for the assistant, and significant potential complications. METHODS: A curriculum using multimedia didactics and 3-D print-based patient-specific surgical simulation was implemented. Six identical 3-D prints were constructed for each of 5 consecutive patients. Preoperative septal myectomy was performed on each printed heart by an attending surgeon and 5 residents. Model myectomy specimen volumes were measured according to liquid displacement. All print resections were videotaped and blindly evaluated by 3 attending surgeons. Pre- and post-test evaluations, and a survey tool were also used to evaluate the curriculum. RESULTS: Baseline myectomy resection volumes differed significantly (attending 15 cm3 vs resident 3.1 cm3; P < .05). Residents resected increasingly larger volumes of tissue over the course of the study. Initial resection volume (compared with faculty) increased by 0.82 cm3 per resection (95% confidence interval, 0.37-1.3 cm3; P < .0001). Total resection volume (compared with faculty) increased by 3.6 cm3 per resection (95% confidence interval, 2.4-4.9 cm3; P < .0001). The residents' survey assessment of the simulator was favorable. CONCLUSIONS: A patient-specific 3-D printing-based simulation module shows promise as a tool to augment and improve cardiothoracic resident training in septal myectomy. The residents were quickly able to perform resections on par with the attending. Residents rated the simulator favorably. Each resident benefited by experiencing the variable anatomy of 5 separate patient-specific models.

Does cramming work? Impact of National Web-Based Thoracic Surgery Curriculum login frequency on thoracic surgery in-training exam performance.

OBJECTIVE: Web-based curricula provide login data that can be advantageously used to characterize and analyze study habits. We sought to compare thoracic surgical trainee In-Training Examination percentiles with regard to their study habits (ie, cramming), as characterized by curriculum login frequency to the national Web-based Thoracic Surgery Curriculum. Furthermore, we then aimed to characterize the curriculum login frequency of trainees as stratified by their performance on the In-Training Examination and their improvement on the In-Training Examination over subsequent years. METHODS: We performed a retrospective review of trainees who accessed the curriculum before the 2014 In-Training Examination, with curriculum login data collected from site analytics. Scores were compared between trainees who crammed (≥30% increase in logins in the month before the In-Training Examination) and those who did not. Trainees were stratified on the basis of 2014 In-Training Examination percentile and improvement in percentile from 2013 to 2014 into high, medium, and low scorers and improvers. RESULTS: Of 256 trainees who took the 2014 In-Training Examination, 63 (25%) met criteria as crammers. Crammers increased total study sessions immediately before the In-Training Examination (P < .001), but without impact on 2014 In-Training Examination percentile (P = .995) or year-to-year improvement (P = .234). Stratification by In-Training Examination percentile demonstrated that highest scoring trainees used the curriculum more frequently in the final month than medium-range scorers (P = .039). When stratified by extent of year-to-year improvement, those who improved the most accessed the curriculum significantly more often in the last month compared with baseline (P = .040). Moreover, those with greatest improvement logged in more in the final month than those with least improvement (P = .006). CONCLUSIONS: Increasing the frequency of study periods on the national Web-based thoracic surgery curriculum before the In-Training Examination may have a unique benefit to trainees who initially score low to allow them to significantly improve their subsequent year In-Training Examination performance.

Long-Term Right Ventricular Assist Device Therapy in an Adult with Pulmonary Atresia/Intact Ventricular Septum.

Durable ventricular assist device (VAD) support is uncommonly employed in adult congenital heart disease and often involves supporting a systemic right ventricle (RV). Ventricular assist device support of a subpulmonic RV is even more unusual.

Flipping the classroom: Case-based learning, accountability, assessment, and feedback leads to a favorable change in culture.

OBJECTIVE: The 88-week Thoracic Surgery Curriculum is challenging to implement because of the large content in a traditional lecture format. This study investigates flipping the classroom by using a case-based format designed to stimulate resident preparation and engagement. METHODS: The didactic conference format was altered. Curricular reading assignments, case review, and conference participation prepared residents for novel formative assessment quizzes. Ten residents participated, and faculty served as controls. Scores were compared with the use of linear regression adjusted for clustering of responses for each person. A survey was administered to determine impressions of this educational technique. RESULTS: A majority of residents completed curricular readings (82%) and reviewed case presentations (79%). Resident performance initially lagged behind faculty but exceeded faculty performance by the conclusion (interaction P = .047). Junior resident overall performance was superior to senior residents over the entire analysis (P = .026); however, both groups improved over time similarly (P = .34) Increased reading from the curriculum (5% increase per level, P = .001) and case presentation review (6% increase per level, P < .0001) were associated with improved quiz performance. Residents presenting cases at their session performed no better than other quiz-takers for the same session (P = .38). The majority of residents viewed this method favorably. CONCLUSIONS: This method stimulated increased resident participation and engagement in this pilot study. Assessment scores increased at both resident levels, and resident performance exceeded faculty performance with time. By using experiential learning principles, flipping the classroom in this manner may improve educational culture by enhancing accountability, assessment, and feedback.

Scan, plan, print, practice, perform: Development and use of a patient-specific 3-dimensional printed model in adult cardiac surgery.

OBJECTIVE: Static 3-dimensional printing is used for operative planning in cases that involve difficult anatomy. An interactive 3D print allowing deliberate surgical practice would represent an advance. METHODS: Two patients with hypertrophic cardiomyopathy had 3-dimensional prints constructed preoperatively. Stereolithography files were generated by segmentation of chest computed tomographic scans. Prints were made with hydrogel material, yielding tissue-like models that can be surgically manipulated. Septal myectomy of the print was performed preoperatively in the simulation laboratory. Volumetric measures of print and patient resected specimens were compared. An assessment tool was developed and used to rate the utility of this process. Clinical and echocardiographic data were reviewed. RESULTS: There was congruence between volumes of print and patient resection specimens (patient 1, 3.5 cm3 and 3.0 cm3, respectively; patient 2, 4.0 cm3 and 4.0 cm3, respectively). The prints were rated useful (3.5 and 3.6 on a 5-point Likert scale) for preoperative visualization, planning, and practice. Intraoperative echocardiographic assessment showed adequate relief of left ventricular outflow tract obstruction (patient 1, 80 mm Hg to 18 mm Hg; patient 2, 96 mm Hg to 9 mm Hg). Both patients reported symptomatic improvement (New York Heart Association functional class III to class I). CONCLUSIONS: Three-dimensional printing of interactive hypertrophic cardiomyopathy heart models allows for patient-specific preoperative simulation. Resection volume relationships were congruous on both specimens and suggest evidence of construct validity. This model also holds educational promise for simulation of a low-volume, high-risk operation that is traditionally difficult to teach.

The Joint Council on Thoracic Surgery Education (JCTSE) "Educate the Educators" Faculty Development Course: Analysis of the First 5 Years.

BACKGROUND: Since 2010, the Joint Council on Thoracic Surgery Education, Inc (JCTSE) has sponsored an annual "Educate the Educators" (EtE) course. The goal is to provide United States academic cardiothoracic surgeons (CTS) the fundamentals of teaching skills, educational curriculum development, and using education for academic advancement. This report describes the course development and evaluation along with attendee's self-assessment of skills through the first 5 years of the program. METHODS: The content of this 2½-day course was based on needs assessment surveys of CTS and residents attending annual meetings in 2009. From 2010 to 2014, EtE was offered to all CTS at training programs approved by the Accreditation Council for Graduate Medical Education. Course content was evaluated by using end-of-course evaluation forms. A 5-point Likert scale (1 = poor, 5 = excellent) was used to obtain composite assessment mean scores for the 5 years on course variables, session presentations, and self-assessments. RESULTS: With 963 known academic CTS in the United States, 156 (16.3%) have attended, representing 70 of 72 training programs (97%), and 1 international surgeon attended. There were also 7 program coordinators. Ratings of core course contents ranged from 4.4 to 4.8, accompanied with highly complementary comments. Through self-assessment, skills and knowledge in all content areas statistically improved significantly. The effect of the course was evaluated with a follow-up survey in which responders rated the program 4.3 on the usefulness of the information for their career and 3.9 for educational productivity. CONCLUSIONS: The EtE program offers an excellent opportunity for academic CTS to enhance their teaching skills, develop educational activities, and prepare for academic promotion. With its unique networking and mentorship environment, the EtE program is an important resource in the evolution of cardiothoracic surgical training in the United States.

Impact of Moodle-Based Online Curriculum on Thoracic Surgery In-Training Examination Scores.

BACKGROUND: The feasibility and efficacy of a web-based curriculum in supplementing thoracic surgical training was previously shown. However, the impact of curricular participation on validated knowledge tests remains unknown. We compared in-service training examination (ITE) results among trainees, stratified by curricular use. METHODS: The national online curriculum was implemented in August 2013. We retrospectively reviewed trainees who participated in thoracic surgical training programs in both 2012 to 2013 and 2013 to 2014. Scores from the 2013 and 2014 ITEs were obtained, and curricular usage data were collected from site analytics. Trainees were separated into three groups according to 2013 ITE scores; within each group, changes in score for high- versus low-volume users were compared. RESULTS: 187 trainees took the ITE both years, with exposure to the online curriculum during only the second year. High-volume users' scores trended toward greater improvement than scores of low-volume users (+18.2% versus +13.0%, p = 0.199). When stratified by 2013 score, the lowest scoring quartile improved substantially, and the highest scoring quartile improved modestly, regardless of curricular use. However, for those individuals who achieved mid-range scores in 2013, there was a trend toward much greater improvement in score with heavier use of the curriculum (+17.0% versus +7.0%, p = 0.094). CONCLUSIONS: Among trainees who had access to the novel online curriculum during the second of 2 consecutive years, we evaluated the impact of curricular participation on ITE scores. The effect appears to be most pronounced in individuals with mid-range scores, in whom high curricular use led to the greatest improvement.