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Overview of the beating-heart OPCAB training model in a human cadaver. ( A ) The training set-up closely resembles the real situation in the OR, which is of incremental value to this model. (B) Beating heart OPCAB model based on the principles shown in Fig. 1. This set-up provides maximum versatility, which can be appreciated in ( C and D ). (C) Set-up for performing the obtuse marginal branch anastomosis. Note that, in this case, the radial artery has already been anastomized with the left internal mammary artery (LIMA) ( ‘ Y-anastomosis ’ ) and the LIMA has already been anastomized with the left anterior descending (LAD) coronary artery. (D) Set-up just after performing the posterior descending artery (PDA) anastomosis. An overview of the entire model with a completed total arterial Y-graft OPCAB with three distal anastomoses.
Source publication
Objectives:
Training models are essential in mastering the skills required for off-pump coronary artery bypass grafting (OPCAB). We describe a new, high-fidelity, effective and reproducible beating-heart OPCAB training model in human cadavers.
Methods:
Human cadavers were embalmed according to the 'Thiel method' which allows their long-term and...
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Citations
... 9 Other authors have created low-fidelity, cost-effective and portable models for aortic root and valve procedures, mitral surgery, ascending aorta replacement as well as aortotomy, aortorrhaphy, coronary proximal and distal anastomosis, but have not been formally evaluated as educational tools. 10,11 Simulation models may also involve the use of cadavers or live animals, for example, for training in endoscopic vein harvesting, 12 beating heart off pump coronary artery bypass (OPCAB) anastomosis 13 and endobronchial ultrasound 14 but the cost and ethical issues surrounding these models pose limitations. ...
Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures. Simulation provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. We aim to describe the current use of simulation in cardiothoracic surgical education and training.
... Most reports were based on cadaveric simulation models and/or cadaveric simulation studies that were conducted at academic medical centers, with the exception of one study that was performed at a community hospital (Sarkar et al., 2018). Only 33.3% (4 of 12) of reports discussed the amount of time required to set-up the simulation model (Aboud et al., 2011;Bouma et al., 2015Bouma et al., , 2017Sarkar et al., 2018). Similarly, cost analysis was performed in only 33.3% (4 of 12) of reports and was often incomplete (Aboud et al., 2011;Bouma et al., 2015;Sarkar et al., 2018). ...
... Only 33.3% (4 of 12) of reports discussed the amount of time required to set-up the simulation model (Aboud et al., 2011;Bouma et al., 2015Bouma et al., , 2017Sarkar et al., 2018). Similarly, cost analysis was performed in only 33.3% (4 of 12) of reports and was often incomplete (Aboud et al., 2011;Bouma et al., 2015;Sarkar et al., 2018). Cost analysis was performed in three of the reports identified in this systematic review. ...
... Cost analysis was performed in three of the reports identified in this systematic review. In the beating heart cadaver model for off pump coronary artery bypass grafting by Bouma and colleagues, the total cost for one day of simulation was reported to be US $5,031, which was inclusive of costs of the skills laboratory operating room and one cadaver (US $2,004), two scrub nurses and a supervising CT surgeon (US $1,022) and all materials and disposables (US $2,004) (Bouma et al., 2015). The cost analysis for the perfused cadaveric model proposed by Carey and colleagues estimated the total cost at US $2,525, including the cost of a single perfused cadaver (US $1,262.55), ...
Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.
... Figure 1 illustrates the flow of study selection. Table 1 illustrates the main surgical specialties for which human cadaver models were used: neurosurgery (n ¼ 13) [18][19][20][21][22][23][24][25][26][27][28][29][30], vascular surgery (n ¼ 11) [28,[31][32][33][34][35][36][37][38][39][40], plastic surgery (n ¼ 5) [28,[41][42][43][44], cardiac surgery (n ¼ 5) [28,[45][46][47][48], abdominal and transplant surgery (n ¼ 1) [47]. Endovascular specialties, such as interventional radiology and cardiology, were only involved in a minority of studies [32,40,[49][50][51]. ...
... The following vascular procedures were carried out in 27 publications: vascular dissection (n ¼ 15) [18][19][20][21][22][25][26][27][28]41,[44][45][46][47]49], vascular anastomosis (n ¼ 12) [18,19,21,22,24,[26][27][28]44,45,47,51], endovascular procedures (n ¼ 11) [31][32][33][34][35][36][37][38][39][40]51], vascular bypass (n ¼ 10) [18,19,22,[25][26][27][28]41,45,51]. Other publications focused on flap and muscle graft surgery (n ¼ 6) [28,30,[41][42][43][44], trauma procedures (n ¼ 4) [28,49,51,52], laparoscopy (n ¼ 1) [47], organ procurement (n ¼ 1) [47] and wound closure (n ¼ 2) [28,44]. ...
... The following vascular procedures were carried out in 27 publications: vascular dissection (n ¼ 15) [18][19][20][21][22][25][26][27][28]41,[44][45][46][47]49], vascular anastomosis (n ¼ 12) [18,19,21,22,24,[26][27][28]44,45,47,51], endovascular procedures (n ¼ 11) [31][32][33][34][35][36][37][38][39][40]51], vascular bypass (n ¼ 10) [18,19,22,[25][26][27][28]41,45,51]. Other publications focused on flap and muscle graft surgery (n ¼ 6) [28,30,[41][42][43][44], trauma procedures (n ¼ 4) [28,49,51,52], laparoscopy (n ¼ 1) [47], organ procurement (n ¼ 1) [47] and wound closure (n ¼ 2) [28,44]. ...
Background: The role of reperfused human cadavers in surgical training has not been established.
Methods: Reports describing reperfused human cadaver models in terms of simulated surgeries, the use of tools to assess technical competency and skills transfer to patients, cadaver status and reperfusion techniques were included.
Results: Thirty-five reports were included. Most participants practised vascular (n = 27), flap (n = 6) and trauma (n = 4) procedures. Training progression was evaluated objectively in only two studies. In two publications, flap techniques were practised on cadavers and repeated successfully in patients. Eighteen studies employed whole bodies. Fresh and embalmed cadavers were both used in 17 publications. Most embalmed cadavers were formalin-fixed (n = 10), resulting in stiffness. Few trainings were offered on soft Thiel-embalmed cadavers (n = 5). Only arteries were reperfused in 20 studies, while in 13 publications, the arteries and veins were filled. Arteries and/or veins were mostly pressurized (n = 21) and arterial flow was generated in 14 studies.
Conclusions: Various reperfused human cadaver models exist, enabling practise of mainly vascular procedures. Preservation method determines the level of simulation fidelity. Thorough evaluation of these models as surgical training tools and transfer effectiveness is still lacking.
... Figure 1 illustrates the flow of study selection. Table 1 illustrates the main surgical specialties for which human cadaver models were used: neurosurgery (n ¼ 13) [18][19][20][21][22][23][24][25][26][27][28][29][30], vascular surgery (n ¼ 11) [28,[31][32][33][34][35][36][37][38][39][40], plastic surgery (n ¼ 5) [28,[41][42][43][44], cardiac surgery (n ¼ 5) [28,[45][46][47][48], abdominal and transplant surgery (n ¼ 1) [47]. Endovascular specialties, such as interventional radiology and cardiology, were only involved in a minority of studies [32,40,[49][50][51]. ...
... The following vascular procedures were carried out in 27 publications: vascular dissection (n ¼ 15) [18][19][20][21][22][25][26][27][28]41,[44][45][46][47]49], vascular anastomosis (n ¼ 12) [18,19,21,22,24,[26][27][28]44,45,47,51], endovascular procedures (n ¼ 11) [31][32][33][34][35][36][37][38][39][40]51], vascular bypass (n ¼ 10) [18,19,22,[25][26][27][28]41,45,51]. Other publications focused on flap and muscle graft surgery (n ¼ 6) [28,30,[41][42][43][44], trauma procedures (n ¼ 4) [28,49,51,52], laparoscopy (n ¼ 1) [47], organ procurement (n ¼ 1) [47] and wound closure (n ¼ 2) [28,44]. ...
... The following vascular procedures were carried out in 27 publications: vascular dissection (n ¼ 15) [18][19][20][21][22][25][26][27][28]41,[44][45][46][47]49], vascular anastomosis (n ¼ 12) [18,19,21,22,24,[26][27][28]44,45,47,51], endovascular procedures (n ¼ 11) [31][32][33][34][35][36][37][38][39][40]51], vascular bypass (n ¼ 10) [18,19,22,[25][26][27][28]41,45,51]. Other publications focused on flap and muscle graft surgery (n ¼ 6) [28,30,[41][42][43][44], trauma procedures (n ¼ 4) [28,49,51,52], laparoscopy (n ¼ 1) [47], organ procurement (n ¼ 1) [47] and wound closure (n ¼ 2) [28,44]. ...
... An overview of the basic principles of the model can be found in Figs 1 and 2. The model is based on our beating-heart off-pump coronary artery bypass grafting training model, which was published previously [4]. ...
... Two formats of simulation (or levels of fidelity) can be identified; non-biological formats (bench models and virtual reality simulators) and biological formats (animal models, human performance simulators and human cadavers) [4,6]. Although basic assessment and training can be performed with low-fidelity simulators and despite the fact that high-fidelity models (such as the beating-heart mitral and aortic valve assessment and valve intervention training model described in this article) have higher costs and limited availability, we were encouraged to pursue and develop this model, because its major strength is that it provides a more complex, realistic environment, which allows direct endoscopic valve assessment in a beating (human) heart. ...
... An endoscopic camera can be inserted (not shown) through the apex for a ventricular view of the mitral and aortic valve, through the left atrial appendage for a left atrial view of the mitral valve, or through the ascending aorta for an aortic view of the aortic valve. Adapted from [4]. countries outside Europe have a legal system for body donation for science and surgical training [4,7]. ...
Objectives:
A thorough understanding of mitral and aortic valve motion dynamics is essential in mastering the skills necessary for performing successful valve intervention (open or transcatheter repair or replacement). We describe a reproducible and versatile beating-heart mitral and aortic valve assessment and valve intervention training model in human cadavers.
Methods:
The model is constructed by bilateral ligation of the pulmonary veins, ligation of the supra-aortic arteries, creating a shunt between the descending thoracic aorta and the left atrial appendage with a vascular prosthesis, anastomizing a vascular prosthesis to the apex and positioning an intra-aortic balloon pump (IABP) in the vascular prosthesis, cross-clamping the descending thoracic aorta, and finally placing a fluid line in the shunt prosthesis. The left ventricle is filled with saline to the desired pressure through the fluid line, and the IABP is switched on and set to a desired frequency (usually 60-80 bpm). Prerepair valve dynamic motion can be studied under direct endoscopic visualization. After assessment, the IABP is switched off, and valve intervention training can be performed using standard techniques.
Results:
This high-fidelity simulation model has known limitations, but provides a realistic environment with an actual beating (human) heart, which is of incremental value. The model provides a unique opportunity to fill a beating heart with saline and to study prerepair mitral and aortic valve dynamic motion under direct endoscopic visualization.
Conclusions:
The entire set-up provides a versatile beating-heart mitral and aortic valve assessment model, which may have important implications for future valve intervention training.
Background
We sought to evaluate our distributed practice program developed for training for beating heart anastomosis by employing a novel beating heart simulator.
Methods
Eleven trainees watched and reviewed instructional video recordings of coronary anastomosis methods with a BEAT + YOUCAN training device, then performed coronary anastomosis procedures under a beating condition. Next, they participated in a four-hour training program developed by faculty surgeons. Ten different anastomosis components were assessed on a five-point rating scale (5, good; 3, average; 1, poor). After finishing the training program, each trainee again performed a coronary anastomosis procedure. Component scores were then compared before and after the training program.
Results
The mean time to completion of the procedure improved from 1033 ± 424 to 795 ± 201 s (p < 0.05). Assessment scores improved from 1.88 ± 0.41 to 2.57 ± 0.30 (p < 0.05). Improvements in some technical components related to handling of instruments were noted (p < 0.05), whereas no significant improvement was seen with arteriotomy, graft orientation, suture management, or knot tying after finishing the training program.
Conclusion
Trainees who participated in our four-hour focused training program for coronary anastomosis with a novel beating heart simulator showed improved ability under the beating condition in regard to technical skills related to handling instruments.
Purpose of review:
The apprentice model has been traditionally used to train cardiac surgery and cardiology learners the techniques for revascularization with the use of simulators recently becoming more prevalent in these training programs. This review aims to summarize research conducted on the use of simulation-based teaching (SBT) for trainees learning percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB).
Recent findings:
Prior literature evaluating the utility of SBT has demonstrated remarkable results including reduced procedural times, use of fluoroscopy, incidence of mistakes, improved stent placement, and confidence with PCI simulators. Similarly, the use of CABG and OPCAB simulators demonstrated improvement in forceps use, needle angles, Objective Structured Assessment of Technical Skill, and reduced completion times. The apprentice model has undoubtedly been successful as the most successful cardiac surgeons and cardiologists have been produced through this training model. Even so, many shortcomings have been identified including insufficient time to teach all relevant technical skills, inadequate exposure to rare adverse events, high-cost, and often unstructured format while being time-consuming and resource-intensive with little objective assessment of proficiency. SBT has been pursued as a potential adjunct to fill the gaps left by the traditional apprentice model. While simulations have been demonstrated to be successful in teaching both experienced and inexperienced learners complex techniques, it is unlikely that training will ever solely rely on simulations. The most efficient method of training learners for revascularization in the future will likely involve a combination of hands-on learning and SBT.
Background
Several training devices have been developed to train anastomotic skills in off-pump coronary artery bypass grafting (OPCAB). However, assessment of trainees’ improvement remains challenging. The goal of this study was to develop a new practical scoring chart and investigate its reliability and utility for anastomotic skills in OPCAB and minimally invasive direct coronary artery bypass (MIDCAB).
Methods
A training device was used, which included a beating heart model installed in a dedicated box. A soft plastic tube was used as the left anterior descending artery, and a porcine ureter was used as the left internal mammary artery. Five cardiac surgery fellows (Fellows, > 5 year of surgical experience) and five residents or medical students (Residents, ≤ 5 year of surgical experience) were enrolled for this study. Before and after training, skills were evaluated using a scoring chart that took into account anastomotic time, leakage, shape, flow measurement, and self-estimation.
Results
Mean total score of all trainees was 15.4 ± 4.0 at pre-training and 18.5 ± 2.4 at post-training (P = 0.05). Before training, there was a significant difference in the total score between Fellows and Residents (18.6 ± 2.2 vs 12.2 ± 2.4 points, P = 0.002), which disappeared after training (19.4 ± 2.5 vs 17.6 ± 2.2 points, P = 0.262). Residents benefitted from training with improvements in their time, total score, score for time, score for flow and subtraction score; however, these effects were not seen in Fellows. The most evident training effect was improvement of self-estimation, which was also seen in Fellows.
Conclusions
Residents were most likely to derive benefit from these training models with regard to both efficiency and quality. Training models seem to have an important role in making surgeons feel more comfortable with the procedure.
Background: Significant advances in minimally invasive implantation of mechanical circulatory support devices have been made. These approaches are technically challenging and associated with a learning curve. Simulation and training opportunities in these techniques are limited. We developed a high-fidelity novel model for minimally invasive left ventricular assist device implantation.
Material and methods: Using a modified inanimate simulator (LSI SOLUTIONS®) and an animal tissue model, a hybrid simulator was created, with a porcine ex vivo heart secured within the inanimate simulator in the normal anatomic position. Key components of the minimally invasive left ventricular assist device implantation were performed, including left ventricular apical coring, attachment of the apical ring, attachment of the assist device, and creation of the aortic-outflow graft anastomosis.
Results: A novel composite inanimate and tissue model for minimally invasive left ventricular assist device implantation was successfully developed. These simulation techniques were reproducible, and the model demonstrated ability to successfully simulate key components of the procedure.
Conclusions: This high-fidelity, reproducible hybrid model allows for crucial components of minimally invasive LVAD implantation to be performed. This model has the potential to be used as an adjunct to surgical training, providing a safe and controlled learning environment for trainees to acquire skills in minimally invasive LVAD implantation.
Objectives:
Today's surgical trainees have less exposure to open vascular and trauma procedures. Lightly embalmed cadavers may allow a reusable model that maximizes resources and allows for repeat surgical training over time.
Methods:
This was a three-phased study that was conducted over several months. Segments of soft-embalmed cadaver vessels were harvested and perfused with tap water. To test durability, vessels were clamped, then an incision was made and repaired with 5-0 polypropylene. Tolerance to suturing and clamping was graded. In a second phase, both an arterial-synthetic graft and an arterial-venous anastomosis were performed and tested at 90 mmHg perfusion. In the final phase, lower extremity regional perfusion was performed and vascular control of a simulated injury was achieved.
Results:
Seven arteries and six veins from four cadavers were explanted. All vessels accommodated suture repair over 6 weeks. There was minor leaking at all previous clamp sites. In the anastomotic phase, vessels tolerated grafting, clamping, and perfusion without tearing or leaking. Regional perfusion provided a life-like training scenario.
Conclusions:
Explanted vessels of soft-embalmed cadavers show adequate durability over time with realistic vascular surgery handling characteristics. This shows promise as initial proof of concept for a reusable perfused cadaver model. Further study with serial regional and whole-body perfusion is warranted.
