Pan-Canadian initiative on Fundamental Competencies for Transcatheter Cardiac Surgery: A modified Delphi consensus study.

OBJECTIVE: Transcatheter cardiac procedures have generated increasing interest in trainees and training programs alike. Using the modified Delphi method, we sought to clarify the transcatheter competencies that cardiac surgery residents should be expected to attain by the completion of training. METHODS: Individuals with expertise in transcatheter structural heart and aortic procedures were recruited across Canada. A questionnaire was prepared using a 5-point Likert scale. During 2 rounds, participants rated the competencies that they thought cardiac surgery residents should be required to achieve to perform transcatheter procedures. Data were analyzed and presented to participants between rounds. Competencies rated 4 or higher by at least 80% of respondents after the second round were considered fundamental to transcatheter cardiac surgical training. RESULTS: A total of 46 individuals participated in the study, including 23 cardiac surgeons, 17 interventional cardiologists, and 6 vascular surgeons. Participants with relevant experience performed a median of 75 (interquartile range, 40-100) transcatheter aortic valve implantations in the prior year as primary or secondary operator and 15 (interquartile range, 11-35) thoracic endovascular aortic repairs in the prior 2 years as primary operator. Median clinical and teaching experience consisted of 13 (interquartile range, 7-19.5) years in practice and 8.5 (interquartile range, 5-15) residents taught per year, respectively. Of the included competencies, 53 were considered fundamental to transcatheter cardiac surgical training. CONCLUSIONS: The identified fundamental competencies can be used to develop educational strategies during transcatheter cardiac surgery training. Future efforts should focus on collecting evidence for their validity.

It's not all about ISCHEMIA: the case for coronary artery bypass grafting in stable coronary artery disease.

PURPOSE OF REVIEW: The recent American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guidelines for Coronary Artery Revascularization have raised concerns on the survival benefits of coronary artery bypass grafting (CABG) over guideline-directed medical therapy (GDMT) in stable coronary artery disease (CAD) and appropriate conduit selection for CABG. This review summarizes the evidence supporting CABG for stable CAD and use of the radial artery as a conduit for CABG. RECENT FINDINGS: CABG has consistently demonstrated a survival benefit over GDMT for patients with stable multivessel CAD. These benefits were more pronounced in patients with diabetes and/or anatomically complex coronary artery disease. The recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial was not designed to and did not include an appropriate patient population to compare revascularization with CABG to GDMT. These results should thus be viewed in the context of previously published studies. Furthermore, increasing evidence suggests that use of a radial artery in CABG is associated with reduced myocardial infarction and repeat revascularization. This should be considered when selecting the appropriate conduits based on underlying patient factors. SUMMARY: Readers should be cautious when applying these guidelines broadly. Appropriate consideration of patient and anatomic factors, and in consultation with a multidisciplinary heart team, is important to achieve the best outcomes for patients.

Validity Evidence for Procedure-Specific Competency Assessment Tools in Cardiovascular and Thoracic Surgery: A Scoping Review.

OBJECTIVE: Surgical education has shifted from a time-based approach to the achievement and demonstration of procedural competency. High quality, objective assessment instruments are required to support this new approach. This study comprehensively reviewed the literature to identify and evaluate available procedure-specific assessment instruments in cardiothoracic and vascular surgery. DESIGN: A systematic search of 8 databases identified studies containing procedure-specific operative assessment instruments in cardiothoracic and vascular surgery. Generic global rating scales were excluded, unless modified to be procedure-specific. Two reviewers independently evaluated the validity evidence, methodological rigour and educational utility of each instrument using objective scoring criteria. Validity evidence was evaluated with a scoring tool aligned with the contemporary framework of validity. Methodological rigour was evaluated using the Medical Education Research Study Quality Instrument. Educational utility was evaluated according to the Accreditation Council for Graduate Medical Education (ACGME) framework. RESULTS: There were 2130 unique studies describing procedure-specific assessment in surgery. Of these, 9 studies evaluating 8 procedure-specific assessment instruments met inclusion criteria for cardiothoracic and vascular surgery. Four instruments were identified in thoracic surgery, 2 in cardiac surgery, and 2 in vascular surgery. Only 1 instrument was designed to evaluate surgeon performance, with the remainder designed to evaluate residents. No single instrument scored the maximum score of 15 for validity evidence. The highest score was 11, with 62.5% (n = 5) of instruments scoring greater than 10. All tools attained high scores in content validity, with minimal evidence generally presented regarding the consequences of assessment using a particular instrument. All but 1 instrument scored greater than 11 out of a maximum 16.5 points for methodological rigour. Very few studies reported on the ACGME domains of educational utility. CONCLUSIONS: In an era where surgical education is shifting towards the demonstration of procedural competency, objective procedure-specific assessment is critical. This review identified that few procedure-specific assessment instruments in cardiothoracic and vascular surgery exist, emphasizing the need for such instruments to ensure the success of competency-based education models.

A scoping review to identify competencies for transcatheter cardiovascular procedures.

OBJECTIVES: Transcatheter procedures are increasingly being recognized as a priority for cardiac surgeons and cardiac surgery trainees. The optimal method of teaching these procedures during residency training has not been established. We used an evidence-based approach to systematically review the literature and identify competencies to inform future paradigms of transcatheter training in cardiac surgery. METHODS: A scoping review was conducted to retrieve relevant literature on the performance of transcatheter cardiovascular procedures, identify competencies required by surgical residents learning to perform these procedures, and develop a preliminary list of competencies for consideration during transcatheter training. MEDLINE, Scopus, and ERIC were queried until April 1, 2020, using a systematic search strategy. No limitations were placed on publication date or type. RESULTS: A total of 1456 sources of evidence were retrieved. After deduplication and screening, there remained 33 that were included in the scoping review, published between 2006 and 2020. The distribution of publication types included 10 comparative studies (30.3% of total), 8 societal statements (24.2% of total), 5 surveys and 5 opinion articles (each 15.2% of total), 2 editorials and 2 descriptions of a simulator (each 6.1% of total), and 1 narrative review (3.0% of total). From these, a total of 400 items were identified and organized into 97 competencies. CONCLUSIONS: Evidence on the competencies required to perform transcatheter cardiovascular procedures is available from a variety of sources. The identified competencies may be a useful resource for developing curricula and teaching transcatheter procedures to cardiac surgery residents.

The study of visuospatial abilities in trainees: A scoping review and proposed model.

BACKGROUND: Visuospatial abilities are an important component of technical skill acquisition. Targeted visuospatial ability training may have positive implications for training programs. The development of such interventions requires an adequate understanding of the visuospatial ability processes necessary for surgical and nonsurgical tasks. This scoping review aims to identify the components of visuospatial ability that have been reported in surgical and nonsurgical trainees and determine if there is consensus regarding the language and psychometric measures used, clarifying the elements that may be required to develop interventions that enhance visuospatial ability. METHODS: A scoping review was designed to identify relevant records from EMBASE and Medline until January 13, 2020. Data were extracted on visuospatial ability terminology, dimensions, instruments, and interventions with results stratified by specialty (surgical, nonsurgical, or mixed). Conference abstracts, opinion pieces, and review studies were excluded. RESULTS: Out of 882 total records, 26 were identified that met criteria for inclusion. Surgical specialities were represented in > 90% of results. A total of 16 unique terms were used to describe visuospatial ability and were measured using 34 instruments, of which eight were used more than once. Eighteen different dimensions were identified. A single study explored the effects of a targeted visuospatial ability intervention. CONCLUSION: A wide range of visuospatial ability terms, instruments, and dimensions were identified, suggesting an incomplete understanding of the components most relevant to surgical and nonsurgical tasks. This confusion may be hindering the development of visuospatial ability targeted interventions during residency training. A rigorous methodological model is proposed to help unify the field and guide future research.

Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations.

PURPOSE OF REVIEW: Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery. RECENT FINDINGS: Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery. SUMMARY: Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.

Two-year outcomes from the PARTNER 3 trial: where do we stand?

PURPOSE OF REVIEW: The PARTNER 3 trial was conducted to compare outcomes after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve and surgical aortic valve replacement (SAVR) in individuals at low surgical risk with aortic stenosis. Recently reported rates of death, stoke and valve thrombosis in the TAVR arm have raised concerns about the longevity of this intervention in low-risk individuals. It is incumbent on all members of the Heart Team to understand the potential consequences of these findings. RECENT FINDINGS: TAVR was initially superior to SAVR at 1 year for a primary composite endpoint of death, stroke and rehospitalization. Results at 2 years now indicate noninferiority. Potential causative factors, comparisons with other transcatheter valves and implications for patients, providers and trainees are explored. Recommendations are additionally provided regarding TAVR and SAVR in individuals with aortic stenosis. SUMMARY: Concerns regarding the longevity of TAVR in low-risk individuals notwithstanding, results from PARTNER 3 indicate that TAVR is at least noninferior to SAVR out to 2 years. Longer follow-up will be required to determine whether these newly founded concerns are justifiable.

The COMPASS trial: practical considerations for application after coronary artery bypass surgery.

PURPOSE OF REVIEW: We review the cardiovascular outcomes for people using anticoagulation strategies (COMPASS) trial with particular emphasis on patients with a history of remote coronary artery bypass grafting (CABG) and those who were enrolled 4-14 days after CABG. We provide practical guidance for selecting patients with the greatest potential to benefit who have acceptable bleeding risk. In particular, we address concerns about postoperative bleeding and discuss the relative merits of rivaroxaban and aspirin versus P2Y12 inhibition and aspirin. RECENT FINDINGS: The COMPASS trial demonstrated that rivaroxaban and aspirin reduce myocardial infarction, stroke, and cardiovascular death in patients with coronary artery disease, without a demonstrated effect on bypass graft patency in the first postoperative year. SUMMARY: After CABG, cardiac surgeons should consider using the COMPASS regimen in patients at high risk of thrombosis whose risk of bleeding is acceptable. If used, the COMPASS regimen should be continued indefinitely in conjunction with other pharmacological risk reduction therapies to prevent long-term atherothrombotic events.