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.

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.

The necessity for clinical reasoning in the era of evidence-based medicine.

Clinical decisions are increasingly driven by evidence-based recommendations of guideline groups, which aim to be based on the highest quality knowledge-randomized clinical trials (RCTs) and meta-analyses. Although RCTs provide the best assessment of the overall value of a therapy, high-quality evidence from RCTs is often incomplete, contradictory, or absent even in areas that have been most exhaustively studied. Moreover, the likelihood of the success or failure of a therapy is not identical in all the individuals treated in any trial because therapy is not the only determinant of outcome. Therefore, the overall results of a trial cannot be assumed to apply to any particular individual, not even someone who corresponds to all the entry criteria for the trial. In addition, the potential for bias due to financial conflicts remains in many guideline groups. Guidelines are key sources of knowledge. Nevertheless, limitations in the extent, quality, generalizability, and transferability of evidence mean that we clinicians must still reason through the best choices for an individual because even in the absence of full and secure knowledge, clinical decisions must still be made. Clinical reasoning is the pragmatic, tried-and-true process of expert clinical problem solving that does value mechanistic reasoning and clinical experience as well as RCTs and observational studies. Clinicians must continue to value clinical reasoning if our aim is the best clinical care for all the individuals we treat.

Use of methylene blue for catecholamine-refractory vasoplegia from protamine and aprotinin.

We present two cases of catecholamine-refractory and vasopressin-refractory vasoplegic syndrome associated with intraoperative anaphylaxis during cardiac surgery. One case was related to the administration of protamine and the other case to the administration of aprotinin. Both cases were successfully managed using intravenous methylene blue. The use of methylene blue blocks accumulation of cyclic guanosine monophosphate by competitively inhibiting the enzyme guanylate cyclase. This results in reduced responsiveness of the vasculature to cyclic guanosine monophosphate-mediated vasodilators, such as nitric oxide. This report provides a description of severe anaphylaxis induced by different agents, in which the use of methylene blue was associated with a significant clinical response.