Objectives
To demonstrate that improvement in technical performance of congenital heart surgical trainees during ventricular septal defect(VSD) closure simulation translates to better patient outcomes.
Methods
Seven trainees were divided into two groups. Experienced-fellows group included four senior trainees who had performed>five VSD closures. Residents group consisted of three residents who had never performed a VSD closure. Experienced-fellows completed 3 VSD closures on real patients as a pretest. Both groups participated in a four-week simulation requiring each participant to complete two VSD closures on 3D-printed models per week. One-month later all trainees returned for a posttest operation in real patients. All performances were recorded, blinded and scored independently by two cardiac surgeons using the validated Hands-On Surgical Training–Congenital Heart Surgery(HOST-CHS). Predefined surgical outcomes were analyzed.
Results
The median HOST-CHS score increased significantly from week one to four [50(39,58) vs.73(65,74), p < 0.001] during simulation. The improvement in the simulation of experienced-fellows successfully transferred to skill acquisition[HOST-CHS score 72.5(71, 74)vs.54(51, 60), p < 0.001], with better patients outcomes including shorter total cross-clamp time[pretest: 86(70,99) vs.posttest: 60(53, 64) min, p = 0.006], and reduced incidence of major patch leak requiring multiple pump runs[pretest: 4/11vs.posttest: 0/9, p = 0.043]. After simulation, the technical performance and surgical outcomes of residents were comparable to experienced-fellows in real patients, except for significantly longer cross-clamp time[Residents : 76.5(71.7,86.8)vs.Experienced-fellows : 60(53,64) min, p = 0.002].
Conclusions
Deliberate practice using simulation translates to better performance and surgical outcomes in real patients. Residents who had never completed a VSD closure could perform the procedures just as safely and effectively as their senior colleagues following simulation.
The commonly used central shunt (i.e. direct connection of the divided main pulmonary artery to the ascending aorta) to facilitate the growth of the diminutive branch pulmonary artery in patients with pulmonary atresia with major aortopulmonary collateral arteries can cause main pulmonary artery distortion, and subsequent disproportional branch pulmonary artery flow and growth. This report describes a novel technique of shunt construction to minimize pulmonary artery torque and tension by using a modified central shunt constructed from autologous pericardium that is anastomosed in an end-to-side fashion to the lateral aspect of the ascending aorta. This shunt will serve as an intermediary conduit to facilitate the main pulmonary artery anastomosis while minimizing torque and tension on the main pulmonary artery. The tension-free connection between the main pulmonary artery and the aorta enabled by the modified central shunt supports proportional pulmonary artery flow and growth in patients with pulmonary atresia, ventricular septal defect, or multiple aortopulmonary collateral arteries and concomitant diminutive native pulmonary arteries.
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