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.

An international survey-based assessment of minimally invasive mitral valve surgery.

OBJECTIVES: Minimally invasive mitral valve surgery (MIMVS) has been shown to be safe and feasible however its adoption has lagged globally. The international consortium is lacking a set of guidelines that are specific to MIMVS. The aim of this study was to capture the practices of MIMVS in different centres. METHODS: A survey was constructed containing 52 multiple-choice and open-ended questions about various aspects of MIMVS. The survey was sent to centres that routinely and frequently perform MIMVS. All surgeons provided informed consent for participating in the survey and publication of data. RESULTS: The survey was sent to 75 known surgeons from whom 32 (42%) completed the survey. All survey responders performed >25 MIMVS cases annually. Twenty (68%) of the surgeons thought that simulation training, MIMVS fellowship and proctorship are all essential prior to commencing an MIMVS program. Eleven (34%) of the surgeons stated that 50-100 MIMVS cases are required to overcome the learning curve, followed by 6 (18%) who said 21-30 cases should suffice. Eighteen (62%) of the surgeons had adopted a fully endoscopic approach for their MIMVS, followed by 15 (51%) surgeons who had performed cases via endoscopic-assisted strategies, 5 (17%) surgeons had conducted the operation under direct visualization and 6 (20%) surgeons had used a robot for their MIMVS. CONCLUSIONS: The study highlights a marked variability on training and approach to MIMVS. Consensus guidelines should be established to allow standardization of MIMVS.

Structure of multidisciplinary heart teams, a survey-based heart team study.

OBJECTIVES: Multidisciplinary approach is well established in various disciplines, with evidence highlighting improved patient outcomes. The objective of this survey was to determine the real-world practice of heart teams across Europe. METHODS: The survey was drafted after a consensus opinion from the authors. The survey was sent to cardiac surgeons and cardiologists identified through electronic search. The survey link and the information sheet were sent through email followed by survey completion reminders. The survey responses were cumulated and analysed. RESULTS: Among 2188 invited clinicians, 220 clinicians from 26 countries took part in the survey (response rate 10%). The completion rate for the survey questions was 85%. A total of 140 (64%) were cardiac surgeons and 80 (36%) were cardiologists. The heart team meeting frequency was weekly according to 104 (55%) respondents. This was conducted face to face according to 139 (73%) of the responses. Eighty-seven (56%) of the respondents reported 10-20% of patients undergoing percutaneous coronary intervention were discussed at the heart team meeting. Seventy-nine (47%) respondents had ad hoc percutaneous coronary intervention institutional guidelines. Fifty-four (32%) respondents reported an audit process for the heart team decisions. CONCLUSIONS: This survey suggests that there is marked variability in the infra-structure and execution of heart teams in different institutions. The results of the survey suggest a need to formulate guidelines on the composition and execution of heart teams which may result in an increase in transparency of decision-making within different institutions in reporting and comparing outcomes.

The role of surgical transcatheter valve implantation for the treatment of severe mitral annular calcification.

With a rise in the aging population, mitral annular calcification is increasingly encountered with an incidence of 10% in over 70 years old. This with increasing patient comorbidities presents a technical challenge due to the risk of atrioventricular disruption which is associated with high operative mortality of up to 75%. We describe two cases of severe mitral disease with marked annular calcification successfully treated with a balloon expandable transcatheter valve which was deployed on cardiopulmonary bypass via a trans-atrial approach.

Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning.

OBJECTIVES: Repeat sternotomy for redo cardiac surgery may be associated with catastrophic injuries to mediastinal structures. The purpose of this study was to determine the frequency of these injuries, associated outcome and if a preoperative computerized tomography (CT) scan reduces the risk of re-entry injury. METHODS: Five hundred and forty-four patients who underwent redo cardiac surgery between 2001 and 2011 were identified by review of our unit's prospectively maintained cardiac surgery database. Demographic details, surgical strategy, re-entry injuries, hospital stay, in-hospital mortality and long-term survival were analysed. RESULTS: The mean age was 61 years; 326 were male, 218 were female. Four hundred and eighty six patients underwent first time redo surgery, while 58 patients had multiple previous operations. The median logistic EuroSCORE was 11, in-hospital mortality rate was 9.5% and observed to expected mortality rate was 0.8. Re-entry complications occurred in 15 cases (2.7%). These included injuries to the aorta (n = 2), right atrium (n = 1), innominate vein (n = 2), internal mammary artery (n = 2), pulmonary artery (n = 2), lung parenchyma (n = 1), saphenous vein graft (n = 2), right ventricle (n = 2) and ventricular fibrillation (n = 1). The mortality rate in patients with re-entry injury was 26% (n = 4) compared with 9% (n = 48) in those without re-entry complications. Preoperative planning by CT scan was performed in 162 cases and adherence of vital structures to the sternum was found in 60 cases; the right ventricle, innominate vein and bypass grafts in 41, 11 and 8, respectively. The incidence rate of re-entry injury was 0.6% in these patients vs 3.6% in those who did not have a preoperative CT scan (P = 0.046). Peripheral arterial cannulation was carried out in 35 patients (6.4%) to establish cardiopulmonary bypass (CPB) prior to sternotomy, and there were no mediastinal injuries observed in these cases. Multivariate logistic regression analysis revealed re-entry injury as one of the independent predictors of in-hospital mortality (P = 0.039). CONCLUSIONS: The incidence of re-entry injury during repeat sternotomy is low; however, it is associated with a significant increase in the risk of in-hospital mortality. Preoperative planning using CT scan reduces the risk by identifying adherent structures, and, in selected patients, establishing CPB prior to sternotomy is a safe strategy in redo cardiac surgery.

Traumatic Bilateral Pneumothoraces due to Sternal Wire Migration.

Sternal wound complications after cardiac surgery are associated with increased morbidity and mortality. Wire migrations associated with sternal dehiscence can lead to catastrophic haemorrhage unless intervened in time. We present a case of sternal wire migration causing bilateral pneumothoraces.