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.

Perspectives in Training and Professional Practice of Cardiac Surgery in Latin America.

INTRODUCTION: There is a lack of information about cardiac surgery training and professional practice in Latin American (LATAM) countries. This study is the first comparative analysis of cardiac surgical training and professional practice across LATAM and provides the fundamentals for future academic projects of the Latin American Association of Cardiac and Endovascular Surgery (LACES). METHODS: International survey-based comparative analysis of the training and professional practice of cardiac surgeons across LATAM. Trainees (residents/fellows) and staf (graduated) surgeons from LATAM countries were included. RESULTS: A total of 289 respondents (staf surgeons N=221 [76.5%]; residents/fellows N=68 [23.5%]) from 18 different countries participated in the survey. Most surgeons (N=92 [45.3%]) reported being unsatisfied with their salaries. Most respondents (N=181 [62.6%]) stated that it was difficult to obtain a leadership position, and 149 (73.8%) stated that it was difficult to find a job after completing training. Only half of the trainee respondents (N=32 [47.1%]) reported that their program had all resident spots occupied. Only 22.1% (N=15) of residents/fellows were satisfied with their training programs. The majority (N=205 [70.9%]) of respondents would choose cardiac surgery as their specialty again. Most surgeons (N=129 [63.9%]) and residents/fellows (N=52 [76.5%]) indicated that the establishment of a LATAM cardiac surgery board examination would be beneficial. CONCLUSION: Modernization and standardization of training, as well as greater access to opportunities, may be required in LATAM to increase professional satisfaction of cardiac surgeons and to reduce disparities in the specialty. Such changes may enhance the regional response to the dynamic challenges in the feld.

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.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis.

OBJECTIVES: Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures. METHODS: We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed. RESULTS: Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay. CONCLUSIONS: In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Becoming a congenital heart surgeon: the long and challenging road.

Training in congenital cardiac surgery is potentially lengthier and more demanding than training in any other surgical field. The duration of training is proportional to the complexity of the specialization. The expertise of a wide range of procedures is required. There is no doubt that some individuals may acquire the requisite abilities with greater ease than others, but fundamentally, these are capabilities that can be taught and learnt. Moreover, congenital cardiac surgeons are required to have a detailed understanding of pathophysiology and morphology, in addition to the stamina and empathy required to manage these complex patients. A fellowship is just the start of such training and is followed by a long road eventually leading to a lifelong journey to become a qualified congenital cardiac surgeon. Effective mentorship is a prerequisite throughout training to guide surgeons on this journey.

Teleproctoring for Training in Structural Heart Interventions: Initial Real-World Experience During the COVID-19 Pandemic.

Background Proctoring represents a cornerstone in the acquisition of state-of-the-art cardiovascular interventions. Yet, travel restrictions and containment measures during the COVID-19 pandemic limited on-site proctoring for training and expert support in interventional cardiology. Methods and Results We established a teleproctoring setup for training in a novel patent foramen ovale closure device system (NobleStitch EL, HeartStitch Inc, Fountain Valley, CA) at our institution using web-based real-time bidirectional audiovisual communication. A total of 6 patients with prior paradoxical embolic stroke and a right-to-left shunt of grade 2 or 3 were treated under remote proctorship after 3 cases were performed successfully under on-site proctorship. No major device/procedure-related adverse events occurred, and none of the patients had a residual right-to-left shunt of grade 1 or higher after the procedure. Additionally, we sought to provide an overview of current evidence available for teleproctoring in interventional cardiology. Literature review was performed identifying 6 previous reports on teleproctoring for cardiovascular interventions, most of which were related to the current COVID-19 pandemic. In all reports, teleproctoring was carried out in similar settings with comparable setups; no major adverse events were reported. Conclusions Teleproctoring may represent a feasible and safe tool for location-independent and cost-effective training in a novel patent foramen ovale closure device system. Future prospective trials comparing teleproctoring with traditional on-site proctoring are warranted.

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.

Resident education in congenital heart surgery does not compromise outcomes.

OBJECTIVE: Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes. METHODS: We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated. RESULTS: Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay. CONCLUSIONS: There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation's quality requires thoughtful approach, including case selection and graded responsibility.

The impact of surgical training on early and long-term outcomes after isolated aortic valve surgery.

OBJECTIVES: Patients presenting with more comorbidities, requiring more complex cardiac surgical procedures and an increase in public scrutiny are impacting on training programme because of the perceived risk of worse outcomes. Hence, we aimed to provide evidence that trainees as the first operator can achieve comparable results to consultants when performing isolated surgical aortic valve replacement. METHODS: From 1996 to 2017, 2919 patients underwent surgical aortic valve replacement at the Bristol Heart Institute, operated on by either a consultant (n = 2220) or a trainee (n = 870) as the first operator. Propensity score matching was used to adjust for imbalance in the baseline characteristics of the 2 groups. RESULTS: Over a 21-year period, the proportion of trainee cases dropped from 41.5% to 25.9%. No differences in the rates and risk of in-hospital mortality, new cerebrovascular accidents, re-exploration for bleeding, deep sternal wound infection and length of stay were found between patients operated on in the 2 groups. Also, there was a comparable risk of late death between the 2 groups (HR 0.88; 95% CI 0.73-1.06; P = 0.27) and this was present regardless of trainees career level and patients surgical risk based on the EuroSCORE. Finally, we showed an increase in patients risk profile in the latest year but, this was not associated with the worst outcomes when trainees performed the operation. CONCLUSIONS: Surgical aortic valve replacement is a safe and reproducible technique and regardless of the patient's risk profile, and no differences in the outcomes between trainees and consultant cases were found.

Impact of the Coronavirus Disease 2019 Pandemic on Cardiac Surgical Education in North America.

OBJECTIVE: We report the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiac surgery trainee education in North America. METHODS: A survey was sent to participating academic adult cardiac surgery centers in North America. Data regarding the effect of COVID-19 on cardiac surgery training were analyzed. RESULTS: Responses were received from 53 academic institutions with diverse geographic distribution. Cardiac surgery trainee re-deployment to alternative clinical duties peaked at the height of the pandemic. We stratified institutions based on high (n = 20) and low burden (n = 33) of patients hospitalized with COVID-19. The majority of institutions have converted didactics (high burden 90% vs low burden 73%) and interviews for jobs/fellowships (high burden 75% vs low burden 73%) from in-person to virtual. Institutions were mixed in preference for administration of the licensing examination, with the most common preference for examinations to be held remotely on normal timeline (high burden 45% vs low burden 30%) or in person with more than 3-month delay (high burden 20% vs low burden 33%). Despite the challenges experienced during the COVID-19 pandemic on trainee clinical experience, re-deployment, and decreased operative volume, institutions expected their trainees to graduate on schedule (high burden 95% vs low burden 91%). CONCLUSIONS: Our study demonstrates that actions taken during the COVID-19 pandemic has led to disruptions in cardiac surgery training with transition of didactics and interviews virtually and re-deployment to alternative duties. Despite this, institutions remain optimistic that their trainees will graduate on schedule.

The Calm Before The Storm: The 4th Year of Medical School prior to a Surgery Residency.

Many medical students figure that their fourth year of medical school should be a time primarily focused on residency interviews and resting up for residency. While the interview part is necessary, the concept that one should be resting during that year is a myth. In fact, nothing could be further from the truth. Your top priority should be to prepare yourself to hit the ground running as a great surgical intern.

Current Status of Simulation Use in Canadian Cardiac Surgery Training Programs.

The apprenticeship model of surgical education, relying solely on operating room training, may be insufficient to meet current needs of cardiac surgery trainees. Challenges such as resident duty hour restrictions, increasing case complexity, and novel techniques limit direct intraoperative experience. Simulation is a widely accepted educational tool in surgery. The purpose of this study was to establish an understanding of the current use of simulation in Canadian cardiac surgery and to examine the attitudes of Canadian educators and residents toward simulation training. Canadian cardiac surgery residents and faculty surgeons were surveyed at each of the 12 Canadian academic institutions. Simulation was used in all 12 academic programs, with the average use being 3 to 4 times a year. The most common simulators used were anastomotic task trainers and porcine heart models. Simulation sessions were deemed incomplete, lacking clearly stated learning objectives and evaluations. There was an overall desire from both residents and faculty surgeons to have more simulation use at their centres. This study identified that although simulation is used and valued within Canada, it is not yet employed to maximum potential. Simulation cannot replace operative experience, but current demands on surgeons and residents mandates a broader, more effective application of simulation as an educational adjunct.

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

ABSTRACT: 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.

Career Research Productivity Correlates With Medical School Ranking Among Cardiothoracic Surgeons.

BACKGROUND: The foundation for a successful academic surgical career begins in medical school. We examined whether attending a top-ranked medical school is correlated with enhanced research productivity and faster career advancement among academic cardiothoracic (CT) surgeons. MATERIALS AND METHODS: Research profiles and professional histories were obtained from publicly available sources for all CT surgery faculty at accredited US CT surgery teaching hospitals in 2018 (n = 992). We focused on surgeons who completed medical school in the United States during or after 1990, the first-year US News & World Report released its annual medical school research rankings (n = 451). Subanalyses focused on surgeons who completed a research fellowship (n = 299) and those who did not (n = 152). RESULTS: A total of 124 surgeons (27.5%) attended a US News & World Report top 10 medical school, whereas 327 (72.5%) did not. Surgeons who studied at a top 10 medical school published more articles per year as an attending surgeon (3.2 versus 1.9; P < 0.0001), leading to more total publications (51.5 versus 27.0; P < 0.0001) and a higher H-index (16.0 versus 11.0; P < 0.0001) over a similar career duration (11.0 versus 10.0 y; P = 0.1294). These differences in career-long research productivity were statistically significant regardless of whether the surgeons completed a research fellowship or not. The surgeons in both groups, however, required a similar number of years to reach associate professor rank (P = 0.6993) and full professor rank (P = 0.7811) after starting their first attending job. CONCLUSIONS: Attending a top-ranked medical school is associated with enhanced future research productivity but not with faster career advancement in academic CT surgery.

Cardiac Surgery Simulation - Part II: Cannulation.

Our group has previously described how dedicated practice outside the operating room can improve surgical technique and enhance intraoperative performance. We have also recently developed a "do-it-yourself" simulator to practice a variety of operative scenarios in cardiac surgery. This video tutorial demonstrates our Cannulation Module, which is designed to hone skills in aortic, right atrial, left ventricular vent, and bicaval cannulation for cardiopulmonary bypass.