Cardiac Surgery Training Research Articles

Is cardiac surgery training really hazardous?

Results Our results showed highly significant difference in the registrars group compared to consultants for cumulative cardiopulmonary bypass time, and aortic cross clamp time; p < 0.01. While there was significant difference concerning post operative chest infection, p < 0.05 in the registrars group. There was no statistically significant difference in logistic euro score, in-hospital mortality, incidence of post operative infection, post operative renal impairment, post operative arrhythmias, ICU readmission, post operative stay, reopening or the need for inotropes.

An Extracorporeal Membrane Oxygenation Cannulation Curriculum Featuring a Novel Integrated Skills Trainer Leads to Improved Performance Among Pediatric Cardiac Surgery Trainees

American Heart Association guidelines recommend timely extracorporeal membrane oxygenation (ECMO) cannulation during cardiopulmonary resuscitation for pediatric cardiac arrest refractory to conventional resuscitation. Traditional cannulation training relies on the apprenticeship model. We hypothesized that a simulation-based ECMO cannulation curriculum featuring a novel integrated skills trainer would improve ECMO cannulation during cardiopulmonary resuscitation performance by cardiothoracic surgery trainees. An embedded surgical neck cannulation trainer, designed in collaboration with expert surgeons, formed the focus for a simulation-based cannulation curriculum. The course included a didactic presentation and 2 neck cannulations during cardiopulmonary resuscitation with video-assisted expert feedback with a further cannulation at 3 months. Primary outcome was time to cannulation on the trainer. Secondary outcomes were performance on a validated Global Rating Scale (GRS) of surgical technique and a novel Composite ECMO Cannulation Score (CECS). Ten cardiothoracic surgery trainees participated. The trainer was rated as authentic, and sessions was rated as highly useful. Median time to cannulation decreased between cannulation 1 and 2 (15 minutes 24 seconds vs. 12 minutes 15 seconds, P = 0.002). Improvement was sustained at 3 months (13 minutes 36 seconds, P = 0.157 vs. attempt 2). Likewise, GRS increased significantly at attempt 2 versus 1 (77% vs. 62%, P = 0.003) as did CECS (88% vs. 52%, P = 0.002). No deterioration in GRS or CECS was measured at 3 months. Cardiothoracic surgery trainees found a contextualized ECMO cannulation during cardiopulmonary resuscitation cannulation curriculum to be highly useful and demonstrated sustained improvement in time to cannulation, CECS, and GRS. Further work will focus on determining the clinical impact of this training and defining the optimal interval and number of training sessions.

Assessment of team training in management of adverse acute events occurring during cardiopulmonary bypass procedure: a pilot study based on an animal simulation model (Fouilloux, Team training in cardiac surgery)

Successful cardiac surgery is highly dependent upon effective and efficient teamwork. Practical training and development will further enhance the team ability to react to a series of low-frequency occurring adverse events during cardiopulmonary bypass (CPB). One of our specialized educational programs focuses on training the whole team. This training is based on an original animal simulation model. The objective of this pilot study was to assess our method of training and learning in an attempt to optimize and improve team management and functioning. Four members of the same cardiac surgery team joined our program. They performed a common procedure, with a cardiopulmonary bypass (CPB) circuit set up to produce several adverse incidents. Events management was analyzed and debriefed in technical and non-technical perspectives. Management of the adverse events was significantly improved. Discussion and debriefing time was fundamental in identifying the most appropriate management for each event. Rescue procedures were assimilated and team training was found to be effective, with the time reduced by up to 50% for 3 events and by up to 70% for air embolism. Our pilot program is an innovative, low-cost tool for the improvement of the management of adverse events occurring during CPB. It includes the different components of surgical education and training. Such an educational tool might be relevant for training. To confirm those encouraging results, it should be assessed in a larger surgical team panel. Further investigations are required for assessing efficiency in real conditions.

Safety and efficiency assessment of training Canadian cardiac surgery residents to perform aortic valve surgery

Research has demonstrated equivalent patient safety outcomes for various cardiac procedures when the primary surgeon was a supervised trainee. However, cardiac surgery cases have become more complex, and the Canadian cardiac surgery education model has undergone some changes. We sought to compare patient safety and efficiency of aortic valve replacement (AVR) between Canadian patients treated by senior cardiac trainees and those treated by certified cardiac surgeons. We completed a single-centre, case-matched, prospectively collected and retrospectively analyzed study of AVR. Patients were matched between trainees and consultants for age, sex, New York Heart Association and Canadian Cardiovascular Society status, urgency of operation and diabetes status. We analyzed 1102 procedures: 624 isolated AVRs and 478 AVRs with coronary artery bypass graft (CABG). For isolated AVR, there was no significant difference in 30-d mortality (p = 0.13) or in major adverse events (p = 0.38) between the groups. In the AVR+CABG group, there was no significant difference in 30-day mortality (p = 0.10) or in the rates of major adverse events (p = 0.37) between the groups. Secondary outcomes (hospital and intensive care unit lengths of stay, valve size and type) did not differ significantly between the groups for isolated AVR or AVR+CABG. Despite a higher-risk patient population and changes in the cardiac surgery training model, it appears that outcomes are not negatively affected when a senior trainee acts as the primary surgeon in cases of AVR.

Assessment of a mitral valve replacement skills trainer: A simplified, low-cost approach

Simulated mitral valve replacement may aid in the assessment of technical skills required for adequate performance in the operating room. We sought to design and assess a mitral valve replacement training station that is low-cost, nonperishable, portable, and reproducible as a first step in developing a mitral valve surgical skills curriculum. Nineteen physicians (7 general surgery residents, 8 cardiothoracic surgery residents, and 4 attending cardiothoracic surgeons) underwent simulated mitral valve replacement testing. Simulated mitral valve replacement was performed on a training station consisting of a replaceable "mitral annulus" inside a restrictive "left atrium." Eight components of performance were graded on a 5-point scale. A composite score (100 point maximum) was calculated by weighting the grades by procedural time. The effect of training level was evaluated using analysis of variance and post hoc Tukey honestly significant difference. The speed of simulated mitral valve replacement varied among general surgery residents, cardiothoracic surgery residents, and attending cardiothoracic surgeons (52.9 ± 9.0 vs 32.8 ± 4.7 vs 28.0 ± 3.5 minutes, respectively; F=25.3; P<.001). Level of training significantly affected all 8 evaluation components (P<.001). Composite scores increased with level of training (general surgery residents 32.9 ± 11.4, cardiothoracic surgery residents 65.1 ± 11.5, and attending cardiothoracic surgeons 88.3 ± 7.8 of a possible 100 points; F=35.7; P<.001). Cardiothoracic surgery residents who reported having performed 10 to 50 mitral valve replacements as the primary surgeon had a composite score of 65.0 ± 2.8 (P<.01 compared with attending cardiothoracic surgeons). Simulated mitral valve replacement can be performed using this simple, affordable, portable setup. Performance scores correlate with level of training and experience, but residents who performed 10 to 50 mitral valve replacements still failed to reach attending-level proficiency. This training simulator may facilitate skills practice and evaluation of competency in cardiac surgery trainees.

Editorial Comment: Nurse practitioners replacing young doctors: it works, but does it make sense?

Editorial Comment: Nurse practitioners replacing young doctors: it works, but does it make sense?

The Cardiac Surgery Workforce: A Survey of Recent Graduates of Canadian Training Programs

The number of applications to Canadian cardiac surgery programs has declined recently. Perception of a difficult job market for new graduates may contribute to this decline. The objective of this survey was to document the experience of recent graduates of Canadian cardiac surgery training programs. A 45-question, web-based survey was distributed to all graduates of Canadian cardiac surgery training programs who completed their training between 2002 and 2008. Of the 62 estimated recent graduates, 50 completed the survey (81%). Mean age was 36 + or - 3 years and 90% were male. The mean number of years of training after medical school was 9.4 + or - 1.6 years; 78% completed a graduate degree; and 27% extended their training because of a lack of jobs. When asked about employment, 74% mostly or definitely got the job they wanted, although 34% considered themselves underemployed. Most respondents (98%) considered finding employment for a new graduate in cardiac surgery today difficult or extremely difficult, and 64% believed that there is currently an excess of cardiac surgeons in Canada. Only 54% of participants would strongly recommend cardiac surgery to potential trainees. The majority of recent graduates from Canadian cardiac surgery training programs were successful in finding secure employment. A substantial proportion, however, extended their training because of a lack of jobs and reported feeling underemployed. Survey respondents agreed that a new graduate might have difficulty finding a job in cardiac surgery today. These concerns may contribute to the challenges of recruiting to the specialty.

Modeling the Cardiac Surgery Workforce in Canada

Limited employment opportunities for recently trained cardiac surgeons are deterring medical students from entering cardiac surgery residency programs. Given the lengthy training period and the aging of both the general population and currently practicing cardiac surgeons, this reduced enrollment raises concerns about the adequacy of the future cardiac surgery workforce. A workforce model was developed to explore the future need for cardiac surgeons in Canada. A novel system dynamics model was developed to simulate the supply and demand for cardiac surgery in Canada between 2008 and 2030 to identify whether an excess or shortage of surgeons would exist. Several different scenarios were examined, including varying surgeon productivity, revascularization rates, and residency enrollment rates. The simulation results of various scenarios are presented. In the base case, a surgeon shortage is expected to develop by 2025, although this depends on surgeons' response to demand-supply gap changes. An alternative scenario in which residency enrollment directly relates to the presence of unemployed surgeons also projects substantial shortages after 2021. The model results indicate that if residency enrollment rates remain at the 2009 level an alarming shortage may develop soon, possibly reaching almost 50% of the Canadian cardiac surgical workforce. These workforce model results project an eventual cardiac surgeon shortage in Canada. This study highlights the possibility of a crisis in cardiac surgery and emphasizes the urgency with which enrollment into cardiac surgery training programs and the employability of recently trained cardiac surgery graduates need to be addressed.

Global Differences in the Training, Practice, and Interrelationship of Cardiac and Thoracic Surgeons

Training and certification for general thoracic surgeons varies enormously between countries. There is little knowledge about training and certification for general thoracic surgeons, and the relationship between thoracic surgery and cardiac surgery around the world. A 38-item survey was designed to assess training, practice, demographics, and relationships of general thoracic and cardiac surgeons. Eighteen cardiothoracic societies representing surgeons on six continents were contacted, and 15 submitted the survey to their membership. The survey was advertised through CTSnet, and 928 surgeons from 105 countries were contacted directly in regions not covered by the professional societies. In all, 1,520 survey respondents were tabulated, representing 95 separate countries. Non-US respondents were younger, more commonly had practices exclusively in cardiac or thoracic surgery, less commonly obtained general surgery certification, less commonly performed esophageal surgery, and had shorter overall surgical training but longer specialized training in cardiothoracic surgery, although US respondents received greater length of cardiac surgery specific training (all p < 0.05). The US respondents thought that cardiac surgery training was more important for the practice of general thoracic surgery than did non-US respondents, and that it was important for thoracic surgeons and cardiac surgeons to be aligned in public policy and specialty advocacy. Marked differences in training and certification across the world result in discrepancies in clinical practice, levels of collaboration between cardiac and thoracic surgeons, and culture and attitude differences that are relevant to the feasibility of alliances relating to public policy. These findings also provide important data to inform any decisions about changes in US cardiothoracic training. Greater international cooperation may diminish these differences in order to propagate improvements in cardiothoracic education, and improve patient access and outcomes through shared specialty advocacy.

Impact of Advances in Invasive Cardiology on Cardiac Surgery

Background:There is a noticeable decline in the number of patients who undergo coronary artery revascularization procedures. The change is definite as it is reported by many centers around the world. This trend is of great concern to cardiac surgeons because of its impact on their practice, its adverse effect on training and the degree of uncertainty it throws into future of the specialty.Methods:The data of the cardiac catheterization laboratory at the King Fahad Cardiac Center in the period between 1986 and 2006 was examined looking at the changing pattern of management of patients who undergo cardiac catheterization.Results:In the early years, angioplasty was attempted in around 10% of patients leaving the rest for surgical consideration or medical therapy. Currently only 15% of patients who undergo selective coronary angiography are referred for surgery. The majority are offered angioplasty and stenting. The trend is towards more catheter-based interventions and less towards surgery.Conclusions:Our findings are in agreement with the general consensus about the specialty. Cardiac surgeons should perhaps consider acquiring new skills which may be outside the operating room. Adding catheter based intervention particularly in valves to cardiac surgery training would be a bonus for the future surgeons that will give them the necessary edge to meet the new challenges. It is incumbent on the leaders in the field to establish a clear strategy for the future.Mini-:Impact of advances in invasive cardiology on cardiac surgery, based on actual analysis of the pattern of referrals to surgery of over two decades.

The Training of Congenital Heart Surgeons

Congenital heart surgery is a specialty characterized by low error tolerance, a high level of cognitive and technical performance, and coordinated efforts of multiple individuals operating within a sophisticated organizational structure. Training in adult and pediatric cardiac surgery is undergoing major changes. In 2007, nearly one-third of American Board of Thoracic Surgery-certified training positions went unfilled. The reasons that are usually cited include a shrinking patient pool (mostly due to percutaneous coronary interventions), the perception of a poorer quality of life for cardiothoracic surgeons (compared to other specialties), declining reimbursements and salaries, a shrinking job market, increased legal challenges, and increased scrutiny by professional societies, payors, and government [9]. Congenital and pediatric heart surgery has been somewhat protected from these changes, although our ‘‘recruits’’ have traditionally come from the general ranks of cardiothoracic surgery trainees. In a recent survey, nearly one-quarter of cardiothoracic surgery training program graduates reported that they would not choose a career in cardiothoracic surgery again, and more than half would not strongly recommend cardiothoracic surgery to potential trainees [5]. The (Long) Road to Becoming a Congenital Heart Surgeon

Improvement in coronary anastomosis with cardiac surgery simulation

Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis. Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed. Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training. In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

Safety of a Cardiac Surgical Training Program over a Twelve-Year Period

The operative results of cardiac surgical procedures performed either by staff surgeons or trainees were compared to evaluate whether there is any additional risk to the patient in operations carried out by trainees. Between 1994 and 2006, 13 197 operations were done by 9 staff surgeons (S-group) and were compared to 1925 operations performed by 10 residents during their training program (R-group). In both groups, subgroups were defined in which patients either underwent isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). Isolated CABG was performed in 8725 cases (S-group) and 1706 cases (R-group). AVR was done in 1273 patients (S-group) and 191 patients in the R-group. The groups were compared with regard to length of surgery, in-hospital mortality, reexploration for bleeding, sternal wound complications, preoperative infarction and stroke. For overall risk stratification, the EuroSCORE was used. In the CABG groups, the KCH score was additionally used. Overall mortality was 0.5 % in the R-group (predicted mortality: 4.6 +/- 5 %) compared to 2 % in the S-group (predicted mortality: 6.9 +/- 7.9 %). Analyzing the CABG groups, mortality was 0.7 % in the R-group (predicted: 1.9 +/- 1.8 %) compared to 1.3 % in the S-group (predicted: 2.1 +/- 2.3 %). The rate of reexplorations for bleeding was 1 % in the R-group compared to 2 % in the S-group ( P < 0.05). Duration of extracorporeal circulation (ECC) was slightly longer in the R-group (95.8 +/- 33 compared to 85.5 +/- 28.3 minutes) without reaching statistical significance ( P > 0.05). Analyzing the AVR group, there was a 0.6 % mortality in the R-group (predicted: 6.5 +/- 6 %) compared to 3.1 % in the S-group (predicted: 8.8 +/- 8 %). Again, there were significantly more reexplorations for bleeding in the S-group (0.6 % vs. 2.8 %, P < 0.05). Time on ECC was longer in the R-group (101.6 +/- 21.6 vs. 96.6 +/- 35 minutes) with a resulting longer cross-clamping time (71.2 +/- 17.1 vs. 63.5 +/- 21 minutes). Training in cardiac surgery can be done with excellent results and no additional risk to the patients. Both groups performed similarly and had outcomes better than the predicted mortality. Training was mostly performed with isolated coronary artery bypass grafting procedures, resulting in only a small surgical spectrum at the time of board certification.

Validation of dynamic heart models obtained using non-linear registration for virtual reality training, planning, and guidance of minimally invasive cardiac surgeries

Current minimally invasive techniques for beating heart surgery are associated with three major limitations: the shortage of realistic and safe training methods, the process of selecting port locations for optimal target coverage from X-rays and angiograms, and the sole use of the endoscope for instrument navigation in a dynamic and confined 3D environment. To supplement the current surgery training, planning and guidance methods, we continue to develop our Virtual Cardiac Surgery Planning environment (VCSP) – a virtual reality, patient-specific, thoracic cavity model derived from 3D pre-procedural images. In this work, we create and validate dynamic models of the heart and its components. A static model is first generated by segmenting one of the image frames in a given 4D data set. The dynamics of this model are then extracted from the remaining image frames using a non-linear, intensity-based registration algorithm with a choice of six different similarity metrics. The algorithm is validated on an artificial CT image set created using an excised porcine heart, on CT images of canine subjects, and on MR images of human volunteers. We found that with the appropriate choice of similarity metric, our algorithm extracts the motion of the epicardial surface in CT images, or of the myocardium, right atrium, right ventricle, aorta, left atrium, pulmonary arteries, vena cava and epicardial surface in MR images, with a root mean square error in the 1 mm range. These results indicate that our method of modeling the motion of the heart is easily adaptable and sufficiently accurate to meet the requirements for reliable cardiac surgery training, planning, and guidance.

Surgical assistants affect SHO training in cardiac surgery

Surgical assistants affect SHO training in cardiac surgery

Risk stratification for training in cardiac surgery.

There is a potential conflict of interest in providing the best possible outcome for patients undergoing cardiac surgery and good training for junior cardiac surgeons. We analysed training with reference to volume of work, risk stratification and outcome for consultant and trainee procedures. The Parsonnet system was used for risk stratification. A retrospective audit was performed for a 6-year period. During the study period, 6037 operations were performed, of which 2166 were carried out by trainees. Direct consultant assistance in a trainee operation varied between 17% and 51% and increased towards the end of the study period. Of the operations performed by trainees, 88% were CABG. The median Parsonnet score for consultant operations was 9 compared with 4 for trainees. Actual mortality was below predicted for all surgeons. Morbidity was also lowest for trainees (10%). With appropriate case selection, trainees in cardiac surgery can achieve good results. As training changes in the UK, trainees should receive increased supervised exposure to a wider range of procedure to compensate for a lower volume of workload.

PROGRESS AND TRAINING IN CARDIAC SURGERY

Australian and New Zealand Journal of SurgeryVolume 48, Issue 4 p. 350-351 PROGRESS AND TRAINING IN CARDIAC SURGERY H. M. WINDSOR, H. M. WINDSORSearch for more papers by this author H. M. WINDSOR, H. M. WINDSORSearch for more papers by this author First published: August 1978 https://doi.org/10.1111/j.1445-2197.1978.tb04874.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume48, Issue4August 1978Pages 350-351 RelatedInformation