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Focused Simulation in Coronary Artery Anastomosis Early in Residency Training
*James I Fann1, John H. Calhoon2, Andrea J. Carpenter2, Walter H. Merrill3, John W. Brown4, Robert S. Poston5, Maziyar Kalani6, Gordon F. Murray7, George L. Hicks, Jr.8, Richard H. Feins9
1Stanford University and VA Palo Alto, Palo Alto, CA;2University of Texas HSC, San Antonio, TX;3University of Cincinnati, Cincinnati, OH;4Indiana University, Indianapolis, IN;5Boston University, Boston, MA;6Stanford University, Stanford, CA;7West Virginia University, Morgantown, WV;8University of Rochester, Rochester, NY;9University of North Carolina, Chapel Hill, NC
BACKGROUND: Cardiothoracic surgery trainees may benefit from intensive simulation training early in residency. We evaluated focused training in coronary artery anastomosis using a porcine heart model and portable task station.
METHODS: At the 2-day Boot Camp, 33 first-year cardiothoracic surgery residents participated in a 4-hour session devoted to coronary anastomosis using a porcine heart model with vein grafts and a portable anastomosis task station on which were mounted 4 mm synthetic vessels. After a brief didactic session, each resident performed end-to-side coronary anastomoses using the porcine model and the task station under direct supervision by attending surgeons (6-7 attendings per group of 8-9 residents) with formative feedback. At beginning, mid-point and end of session, performance of components of anastomosis was evaluated using a 3-point rating scale (1=good: able to accomplish goal without hesitation, showing good progress and flow; 2=average: able to accomplish goal with hesitation, discontinuous progress and flow; 3=below average: able to partially accomplish goal with hesitation). Resident progress at beginning and end of session was video recorded and reviewed by three experienced surgeons in a blinded fashion. After the session, the participants completed an exit questionnaire. All residents were given a portable task station at the end of the course for distributed and deliberate practice.
RESULTS: Total number of end-to-side anastomoses using the porcine heart model and the task station ranged from 10 to 18. Performance rating scores based on immediate assessment are noted in the Table (see below). Review of the video recordings of anastomoses confirmed the performance improvement. Exit questionnaire showed 100% of residents agreed that the task station and porcine model were good methods of training technical skills. All residents considered the porcine model to be realistic and stressed important components of an anastomosis. While nearly all indicated that the task station stressed important components, 61% of residents believed that performing an anastomosis using the task station was realistic. All residents were more confident in their ability to perform coronary anastomosis after the session.
CONCLUSIONS: In general, the 4-hour focused training using porcine heart model and the task station resulted in improved ability to perform an anastomosis based on immediate assessment and confirmed by review of the video record. Simulation with focused training and emphasis on distributed and deliberate practice may be useful in preparing residents for coronary anastomosis in the clinical setting.
Performance rating scores based on immediate assessment | Beginning | Mid-point | End | p-value | | Graft orientation | 2.30+0.50 | 1.86+0.46 | 1.36+0.47 | p<0.001 | | Bite appropriate | 2.29+0.56 | 1.77+0.50 | 1.36+0.47 | p<0.001 | | Spacing appropriate | 2.33+0.51 | 1.89+0.45 | 1.35+0.46 | p<0.001 | | Needle holder use | 2.20+0.67 | 1.80+0.51 | 1.29+0.45 | p<0.001 | | Use of forceps | 2.11+0.58 | 1.76+0.63 | 1.50+0.56 | p<0.001 | | Needle angles | 2.44+0.48 | 1.91+0.49 | 1.42+0.49 | p<0.001 | | Needle transfer | 2.24+0.49 | 1.89+0.50 | 1.58+0.50 | p<0.001 | | Suture management and tension | 2.33+0.62 | 1.88+0.52 | 1.58+0.50 | p<0.001 | | Data expressed as mean+SD; paired t-test for beginning vs. mid-point, beginning vs. end, mid-point vs. end. |
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